Hidradenitis suppurativa

Last Updated: 2021-10-18

Author(s): Anzengruber, Navarini

Verneuil 1854, Plewig & Steger 1989

Acne inversa, Verneuil's disease

Chronic recurrent inflammation of the hair follicles (terminal hairs) in the intertriginous areas with comedo, abscess, fistula and scarring formation. It is not a primary sweat gland inflammation.

  • Prevalence: 1%
  • Incidence: Varying data, whs. 1:600
  • Peak in incidence: 28- 64 years
  • Women > men (controversial)
Hurley grade Abscesses Scarring strands Flatulent infestation
I + - -
II + + -
III + + +
  • Acne triad
    • Acne conglobata
    • Hidradenitis suppurativa
    • Perifolliculitis capitis abscedens et suffodiens
  • Acne tetrad
    • Acne conglobata
    • Hidradenitis suppurativa
    • Perifolliculitis capitis abscedens et suffodiens
    • Pilonidal sinus
  • Unexplained
  • Associations
    • Psoriasis
    • Chronic inflammatory bowel disease
    • Rheumatoid factor-negative polyarthritides
    • Hypertension
    • Pyoderma gangraenosum
    • Systemic amyloidosis
  • Predisposition factors:
    • Nicotine consumption
    • Adiposity
    • Tight clothing or friction
    • Hyperhidrosis (controversial)
  • Inflammatory nodules and abscesses in the area of the intertrigines, genital and below the breasts/rarely around the nipples
  • Follicular hyperkeratosis (not always present) leads to the formation of comedones
  • Unique clinic (at least 2 abscesses within 6 months in the area of the intertrigines)
  • Presence of risk factors combined with clinic
  • Remaining acne tetrad

Hurley Score:

  1. Single or multiple abscesses without scarring or fistulae
  2. Recurrent abscesses, single or widely spaced, with fistula formation
  3. Diffuse or broad-based, multiple associated lesions with fistulae and abscesses. Scars may lead to limitation of movement, as well as functional impairment (genitoanal area).

IHS4 score
Number of nodules x1
Number of abscesses x2
Fistulas / sinuses x4

<4 points: mild HS
4-10 points: moderate HS
>10 points: severe HS

Axillary, inguinal, perianal, perineal, scrotum, submammary, retroauricular.

  • Recurrence post OP
    • Axillary approx. 3%
    • Inguino-perineal approx. 35%
    • Submammary approx. 50%
  • Pararectal fistula
  • Urethral fistulas
  • Movement restrictions
  • Genital lymphoedema
  • Squamous cell carcinoma
  • Higher risk of cerebrovascular insult, coronary artery disease, heart failure, pAVK
  • Weight reduction
  • Loose, non-frictional clothes
  • Avoiding nicotine abuse

Chronic, recurrent disease. Reduction of obesity and cessation of nicotine abuse can lead to significant improvement and healing in some patients (this has already been observed several times). However, this is hardly to be expected in those forms that occur without the prior presence of the risk factors.

Topical therapy (only sufficient for grade I and mildly pronounced grade II):

  • Topical clindamycin 2x a day for 3 months
    • To avoid resistance, always prescribe together with antiseptic skin wash lotion 1x daily
  • Inject triamcinolone Kenacort A40 1:1 lidocaine into the nodules

Systemic therapy

  • Doxycycline p.o. 100 mg 2x daily for 3 months, if necessary reduction to 100mg 1x daily
  • Rifampicin & clindamycin
    • Clindamycin p.o. 300 mg 2x daily and rifampicin p.o. 300 mg 2x daily for 3 months
  • TNF-alpha inhibitors
    • Adalimumab s.c. 160 mg (week 0), 80 mg (week 1), 80 mg 1x weekly, or 80mg every 2 weeks
  • Antiandrogenic therapy (controversial)

Other off-label therapies

  • Infliximab i.v. 5 mg kg body weight in week 0, 2, 6 and every 8 weeks thereafter
  • Certolizumab pegol in young women
  • Zinc gluconate p.o. 90 mg 1x daily for 3 months
  • Acitretin
  • Metformin
  • Secukinumab

Isotretinoin is NOT indicated except in acne triad/tetrade!

Surgical excision

  • Can be performed at all 3 stages
  • Deroofing of abscesses by punch biopsy (6s) can lead to effective drainage and healing
  • Is low recurrence
  • Wide excision and secondary healing can lead to months of healing, no longer feasible at the hospital

Laser

  • CO2 laser for ablation of single foci works very well
  • Hair removal laser
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