Medical and Surgical Management of Hidradenitis Suppurativa: A Review of International Treatment Guidelines and Implementation in General Dermatology Practice

Abstract

Background: Hidradenitis suppurativa (HS) is a chronic painful skin disease that severely impairs patients' quality of life. While high-quality trials of HS therapies remain limited, medical knowledge of best treatment practices is rapidly evolving, leading to the recent publication of multiple international treatment guidelines for HS.

Summary: This review compares international HS treatment guidelines, describes evidence for effectiveness of common and emerging HS therapies, and provides guidance for integrating evidence-based HS care into practice. Although over 50 medical and procedural treatments are mentioned across international HS guidelines, only adalimumab and infliximab have grade B/weak recommendation or higher across all major guidelines. This review describes the appropriate patient selection and effectiveness of the most commonly used medical and procedural treatments for HS. It also includes recommendations for counseling, dosing, and duration of medical therapies as well as procedure videos for the practicing dermatologist.

Keywords: Acne inversa; Biologicals; Hidradenitis suppurativa; Surgical techniques.

Figure 1:

Treatment of inguinal HS using Nd:YAG laser (A) Right medial thigh prior to treatment. (B) Right medial thigh following 3 treatments.

Figure 2 –

Deroofing technique (A) Following local anesthesia, a double-ended fistula probe is used to delineate extent of a well-demarcated cutaneous sinus. (B) Iris scissor used over top of the probe to open the sinus. (C) Removal of tissue overlying the sinus to create a beveled edge. (D) The dermal base of the sinus tract is left intact after probing reveals no lateral extension. To ensure that the floor of the sinus tract remains intact, contents of the sinus tract should be removed using gentle debridement or gauze grattage. (E) Wound after hemostasis using aluminum chloride solution and electrocautery. (F) Healed wound 5 weeks after deroofing.

Figure 3 -

Comparison of sinus tract removal by excision vs deroofing technique (A) Cross sectional view of sinus tract prior to intervention. This sinus tract extends through the reticular dermis and closely approaches the subcutaneous fat. The base/floor of the sinus tract is outlined in purple, and the epithelium on the roof/top of the sinus tract is red. (B) Excision - The borders of the entire sinus tract are outlined clinically and excision is extended to the subcutaneous fat. Intraoperative fistula probe is used to detect any additional interconnecting tracts, and the margins are extended laterally if appropriate. (C) Excision - Surgical defect after excision. Note, the base of the sinus tract is completely removed in HS sinus tract excision. (D) Deroofing -Scissors are used to remove the epithelium overlying the sinus tract. (E) Deroofing - After the entire roof of the sinus tract is removed and probing reveals no further extension, gelatinous material is removed from sinus tract using gentle gauze grattage. Rough debridement may result in defects in the floor of the sinus tract, which prolongs healing time. (F) Deroofing - Surgical defect after deroofing. The epithelium at the base of the sinus tract, marked in purple, remains intact.

Figure 4:

Wound healing following surgical excision of HS sinus tract (A) Prior to excision, (B) Post-operative day 4, (C) Post-operative week 6, and (D) Post-operative month 4

Figure 5:

Wound healing following CO₂ excision of right axilla (A) Prior to excision, (B) Immediately post-op, (C) Post-operative day 3, (D) Post-operative week 2, (E) Post-operative week 3, (F) Post-operative week 30