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Hidradenitis Suppurativa

Hidradenitis Suppurativa. B. Wayne Blount, MD, MPH. Objectives. List the diagnostic criteria for Hidradenitis Suppurativa (HS) Know the usual presentation for HS List the pertinent parts of the focused history & P.E. for HS Name the severity assessment stages of HS

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Hidradenitis Suppurativa

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  1. Hidradenitis Suppurativa B. Wayne Blount, MD, MPH

  2. Objectives • List the diagnostic criteria for Hidradenitis Suppurativa (HS) • Know the usual presentation for HS • List the pertinent parts of the focused history & P.E. for HS • Name the severity assessment stages of HS • Name the 1st line treatment options for HS • List some of the alternative treatments for HS

  3. Definition • A chronic disease characterized by chronic or recurrent abscesses, sinus tracts and scarring of apocrine gland-bearing skin • Prevalence of 1%

  4. Can occur in children, BUT most often appears after puberty • Rare among aged • Prognosis is poor, as one hallmark is chronicity

  5. Where is “apocrine gland-bearing skin” ?

  6. Diagnostic Criteria • Typical lesions • Typical topography • Chronicity and recurrences

  7. Typical lesions • Deep-seated painful nodules • Abscesses • Draining sinuses • Bridged scars • Open comedones

  8. Painful Nodules

  9. Abscess

  10. Draining Sinus

  11. Bridged Scars

  12. Open Comedones

  13. Diagnostic Criteria • Typical lesions • Typical topography • Chronicity and recurrences

  14. Typical Topography • Axillae • Groin • Perineum • Perianal • Buttocks • Infra- & Inter- mammary folds

  15. Axillae

  16. Groin

  17. Perineum & Perianal

  18. Buttocks

  19. Mammary Folds

  20. Etiology • Unknown • An “orphan” disease • Several hypotheses: none proven

  21. Risk Factors • Smoking • Overweight • Female preponderance • Routine cultures are most often negative. • In abscesses, numerous bacteria are recovered

  22. Diagnostic Criteria • Typical lesions • Typical topography • Chronicity and recurrences

  23. Diagnosis ? • Recurrent boils in last 6 months? • In Armpits or groin?

  24. Clinical Presentation • Classified into primary and secondary lesions • Primary: Solitary nodules, boils or abscesses • Secondary: Sinuses, Scars.: result from repetitive attacks

  25. Clinical Presentation • Multifocal & often subclinical in predisposed areas

  26. Differential Diagnoses • Carbuncles • Furuncles • Bartholin’s abscess • Epidermal cysts • Lymphogranuloma venereum • Nodular acne • Pilonidal Cyst • Crohn’s

  27. Complications • Acute infections • Lymphatic obstruction • Squamous cell carcinoma • Depression • Anemia • Malaise • Fistuale

  28. Severity Assessment • “Hurley” stages: based on degree of inflammation & fibrosis • Hurley stage 1 : Abscess(es) without sinuses or scarring • Hurley 2: recurrent abscesses with tract formation & scarring • Hurley 3: Multiple interconnected tracts & abscesses thruout an entire area

  29. Hurley Stage 1

  30. Hurley Stage 2

  31. Hurley Stage 3

  32. Hurley Stage 3

  33. Sartorius Score • Based on # of regions involved, number of lesions & # of types of lesions, Distance between 2 lesions, if all lesions are separated by normal skin.

  34. Don’t forget to ask the patient how much pain there is and their quality of life & # of flares

  35. Treatment • Medical • Topical • Systemic • Surgical • Traditional • Laser • Other

  36. MedicalTopical • Clindamycin : B Rec • 15% Resorcinol peels : C Rec • Intralesional TAC: C Rec for single lesions

  37. MedicalSystemic • Clindamycin & Rifampicin: (both 300 mg BID X 3 months) B Rec • TCN: 500 mg BID x 3 months: B Rec • Immunosupressants: • Steroids: B Rec, but get rebound flares when stopped • Cyclosporine: B Rec • TNF-a inhibitors: B Rec, Etanercept, adalimumab, & Infliximab • Methotrexate: D Rec

  38. MedicalSystemic • Dapsone: B Rec • Anti-androgens: C Rec • Isotretinoin : D Rec

  39. Surgical • The principal treatment for chronic, relapsing & severe HS : B Rec • The wider the excision, the better: C Rec • Healing by 2ndary intention is better: C Rec • HS is a generalized disease at onset, so will get recurrences at sites & in regions no6t “surgerized”.

  40. Surgical • Laser : More appropriate for intermediate severity : B Rec

  41. Other Treatments • Oral Zinc Salts (90 mg of zinc gluconate): B Rec for Hurley Stages 1 & 2 • Botulinum: B Rec • Cryotherapy: D Rec • Radiotherapy: C Rec, afetr others have failed • Smoking cessation: A Rec • Weight loss: A Rec

  42. Treatment • Varies with disease severity, frequency of exaccerbations and patient goals. • Multimodal therapy is usual • Stage 1 or early disease (no or little scarring): topical clindamycin BID • 1 lesion at a time: localized surgery or topical medical Rx

  43. Treatment • This is a chronic disease • Cannot just I & D & put on 10 day course of ABX • Manage expectations • Follow Up and shared decision-making

  44. Treatment • Intermediate severity: • Systemic medical and consider surgery

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