Hidradenitis Suppurativa: Rapid Evidence Review
Am Fam Physician. 2019 Nov 1;100(9):562-569.
Patient information: A handout on this topic is available at https://familydoctor.org/condition/hidradenitis-suppurativa/
Author disclosure: Drs. Wipperman and Bragg have no financial affiliations. Dr. Litzner does not have a formal relationship with any commercial company to disclose, but a public database revealed food and beverage listings for several of the drugs mentioned in this article. None of these involved cash payments, and they are not considered a violation of our conflict-of-interest policy.
Article Sections
Hidradenitis suppurativa is a chronic folliculitis affecting intertriginous areas. Onset generally occurs in young adulthood to middle adulthood (18 to 39 years of age). Females and blacks are more than twice as likely to be affected. Additional risk factors include family history, smoking, and obesity. Hidradenitis suppurativa is associated with several comorbidities, including diabetes mellitus and Crohn disease. The clinical presentation of hidradenitis suppurativa ranges from rare, mild inflammatory nodules to widespread abscesses, sinus tracts, and scarring. Quality of life is often affected, and patients should be screened for depression. Treatment includes wearing loose-fitting clothes, losing weight if overweight, and smoking cessation. Topical clindamycin alone can be effective for patients with mild disease. Patients with moderate disease can be treated with oral antibiotics, such as tetracyclines, in addition to topical clindamycin. Adalimumab, a tumor necrosis factor alpha inhibitor, is effective for patients with moderate to severe hidradenitis suppurativa. Surgical procedures are often necessary for definitive treatment and include local procedures, such as punch debridement and unroofing/deroofing. Wide excision is indicated for patients with severe, extensive disease and scarring.
Hidradenitis suppurativa, also known as acne inversa, is a chronic folliculitis that causes deep scarring and impacts quality of life.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence Rating | Comments |
|---|---|---|
Smoking cessation and weight loss should be encouraged to decrease disease severity and improve response to treatment.3,4,11,12 | B | Consistent results from lower-quality cohort studies |
Topical clindamycin and oral tetracycline antibiotics are effective for patients with mild to moderate hidradenitis suppurativa.15,19,27 | B | Evidence from limited-quality RCTs |
Adalimumab (Humira) is effective for patients with moderate to severe hidradenitis suppurativa.24,25,27 | A | Consistent evidence from high-quality RCTs |
Wide excision is the definitive treatment for severe hidradenitis with extensive involvement and scarring.34,35 | B | Systematic review and meta-analysis of lower-quality clinical trials |
RCTs = randomized controlled trials.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence Rating | Comments |
|---|---|---|
Smoking cessation and weight loss should be encouraged to decrease disease severity and improve response to treatment.3,4,11,12 | B | Consistent results from lower-quality cohort studies |
Topical clindamycin and oral tetracycline antibiotics are effective for patients with mild to moderate hidradenitis suppurativa.15,19,27 | B | Evidence from limited-quality RCTs |
Adalimumab (Humira) is effective for patients with moderate to severe hidradenitis suppurativa.24,25,27 | A | Consistent evidence from high-quality RCTs |
Wide excision is the definitive treatment for severe hidradenitis with extensive involvement and scarring.34,35 | B | Systematic review and meta-analysis of lower-quality clinical trials |
RCTs = randomized controlled trials.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
Epidemiology
The prevalence of hidradenitis suppurativa in the United States is approximately 0.1%, with increasing incidence over the past 10 years.1,2
Onset of hidradenitis suppurativa occurs in young adulthood to middle adulthood (18 to 39 years of age).1
Nonmodifiable risk factors include family history, female sex (incidence of 16.1 and 6.8 per 100,000 for females and males, respectively), and black race (incidence of 30.6 and 11.7 per 100,000 in blacks and whites, respectively).1
Modifiable risk factors include cigarette smoking and obesity.3,4
Hidradenitis suppurativa is associated with several systemic conditions, including diabetes mellitus and Crohn disease (Table 1).5,6
Systemic Conditions Associated with Hid
References
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24. Kimball AB, Okun MM, Williams DA, et al. Two phase 3 trials of adalimumab for hidradenitis suppurativa. N Engl J Med. 2016;375(5):422–434.
25. Zouboulis CC, Okun MM, Prens EP, et al. Long-term adalimumab efficacy in patients with moderate-to-severe hidradenitis suppurativa/acne inversa: 3-year results of a phase 3 open-label extension study. J Am Acad Dermatol. 2019;80(1):60–69e62.
26. Grant A, Gonzalez T, Montgomery MO, et al. Infliximab therapy for patients with moderate to severe hidradenitis suppurativa: a randomized, double-blind, placebo-controlled crossover trial. J Am Acad Dermatol. 2010;62(2):205–217.
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35. Mehdizadeh A, Hazen PG, Bechara FG, et al. Recurrence of hidradenitis suppurativa after surgical management: a systematic review and meta-analysis. J Am Acad Dermatol. 2015;73(5 suppl 1):S70–S77.
36. Mahmoud BH, Tierney E, Hexsel CL, et al. Prospective controlled clinical and histopathologic study of hidradenitis suppurativa treated with the long-pulsed neodymium: yttrium-aluminium-garnet laser. J Am Acad Dermatol. 2010;62(4):637–645.
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39. DeFazio MV, Economides JM, King KS, et al. Outcomes after combined radical resection and targeted biologic therapy for the management of recalcitrant hidradenitis suppurativa. Ann Plast Surg. 2016;77(2):217–222.
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