Hidradenitis Suppurativa: Rapid Evidence Review

Jennifer Wipperman; Dee Ann Bragg; Brandon Litzner

Nov 1, 2019 Issue

Hidradenitis Suppurativa: Rapid Evidence Review

JENNIFER WIPPERMAN, MD, MPH; DEE ANN BRAGG, MD; and BRANDON LITZNER, MD University of Kansas School of Medicine–Wichita, Wichita, Kansas

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.

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.

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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.

Epidemiology

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Abstract
Epidemiology
Pathophysiology
Clinical Features
Treatment
References

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

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TABLE 1.

Systemic Conditions Associated with Hidradenitis Suppurativa

Arthritis and spondyloarthropathy

Crohn disease

Diabetes mellitus

Metabolic syndrome

Polycystic ovary syndrome

Pyoderma gangrenosum

Trisomy 21 (Down syndrome)

Information from references 5 and 6.

TABLE 1.

Systemic Conditions Associated with Hid

The Authors

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JENNIFER WIPPERMAN, MD, MPH, is an associate professor in the Department of Family and Community Medicine at the University of Kansas School of Medicine–Wichita and Via Christi Family Medicine Residency, Wichita....

DEE ANN BRAGG, MD, is an assistant professor in the Department of Family and Community Medicine at the University of Kansas School of Medicine–Wichita and is associate director of the Via Christi Family Medicine Residency.

BRANDON LITZNER, MD, is a clinical instructor in the Department of Family and Community Medicine at the University of Kansas Medical Center–Wichita and is a dermatologist/dermatopathologist at the Via Christi Clinic, Ascension Medical Group.

Address correspondence to Jennifer Wipperman, MD, MPH, University of Kansas School of Medicine, 1010 N. Kansas, Wichita, KS 67214 (email: jennifer.wipperman1@ascension.org). Reprints are not available from the authors.

References

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1. Garg A, Kirby JS, Lavian J, et al. Sex- and age-adjusted population analysis of prevalence estimates for hidradenitis suppurativa in the United States. JAMA Dermatol. 2017;153(8):760–764....

2. Garg A, Lavian J, Lin G, et al. Incidence of hidradenitis suppurativa in the United States: a sex- and age-adjusted population analysis. J Am Acad Dermatol. 2017;77(1):118–122.

3. Garg A, Papagermanos V, Midura M, et al. Incidence of hidradenitis suppurativa among tobacco smokers: a population-based retrospective analysis in the U.S.A. Br J Dermatol. 2018;178(3):709–714.

4. Sartorius K, Emtestam L, Jemec GB, et al. Objective scoring of hidradenitis suppurativa reflecting the role of tobacco smoking and obesity. Br J Dermatol. 2009;161(4):831–839.

5. Shlyankevich J, Chen AJ, Kim GE, et al. Hidradenitis suppurativa is a systemic disease with substantial comorbidity burden: a chart-verified case-control analysis. J Am Acad Dermatol. 2014;71(6):1144–1150.

6. Yadav S, Singh S, Edakkanambeth Varayil J, et al. Hidradenitis suppurativa in patients with inflammatory bowel disease: a population-based cohort study in Olmsted County, Minnesota. Clin Gastroenterol Hepatol. 2016;14(1):65–70.

7. Boer J, Weltevreden EF. Hidradenitis suppurativa or acne inversa. A clinicopathological study of early lesions. Br J Dermatol. 1996;135(5):721–725.

8. von Laffert M, Helmbold P, Wohlrab J, et al. Hidradenitis suppurativa (acne inversa): early inflammatory events at terminal follicles and at interfollicular epidermis. Exp Dermatol. 2010;19(6):533–537.

9. Shah N. Hidradenitis suppurativa: a treatment challenge. Am Fam Physician. 2005;72(8):1547–1552. Accessed July 15, 2019. https://www.aafp.org/afp/2005/1015/p1547.html

10. Saunte DM, Boer J, Stratigos A, et al. Diagnostic delay in hidradenitis suppurativa is a global problem. Br J Dermatol. 2015;173(6):1546–1549.

11. Kromann CB, Ibler KS, Kristiansen VB, et al. The influence of body weight on the prevalence and severity of hidradenitis suppurativa. Acta Derm Venereol. 2014;94(5):553–557.

12. Denny G, Anadkat MJ. The effect of smoking and age on the response to first-line therapy of hidradenitis suppurativa: an institutional retrospective cohort study. J Am Acad Dermatol. 2017;76(1):54–59.

13. Kouris A, Platsidaki E, Christodoulou C, et al. Quality of life and psychosocial implications in patients with hidradenitis suppurativa. Dermatology. 2016;232(6):687–691.

14. Thorlacius L, Cohen AD, Gislason GH, et al. Increased suicide risk in patients with hidradenitis suppurativa. J Invest Dermatol. 2018;138(1):52–57.

15. Clemmensen OJ. Topical treatment of hidradenitis suppurativa with clindamycin. Int J Dermatol. 1983;22(5):325–328.

16. Pascual JC, Encabo B, Ruiz de Apodaca RF, et al. Topical 15% resorcinol for hidradenitis suppurativa: an uncontrolled prospective trial with clinical and ultrasonographic follow-up. J Am Acad Dermatol. 2017;77(6):1175–1178.

17. Saunte DM, Jemec GB. Hidradenitis suppurativa: advances in diagnosis and treatment. JAMA. 2017;318(20):2019–2032.

18. Altenburg J, de Graaff CS, van der Werf TS, et al. Immunomodulatory effects of macrolide antibiotics–part 1: biological mechanisms. Respiration. 2011;81(1):67–74.

19. Jemec GB, Wendelboe P. Topical clindamycin versus systemic tetracycline in the treatment of hidradenitis suppurativa. J Am Acad Dermatol. 1998;39(6):971–974.

20. Bettoli V, Zauli S, Borghi A, et al. Oral clindamycin and rifampicin in the treatment of hidradenitis suppurativa-acne inversa: a prospective study on 23 patients. J Eur Acad Dermatol Venereol. 2014;28(1):125–126.

21. Dessinioti C, Zisimou C, Tzanetakou V, et al. Oral clindamycin and rifampicin combination therapy for hidradenitis suppurativa: a prospective study and 1-year follow-up. Clin Exp Dermatol. 2016;41(8):852–857.

22. Vossen AR, van Straalen KR, Prens EP, et al. Menses and pregnancy affect symptoms in hidradenitis suppurativa. J Am Acad Dermatol. 2017;76(1):155–156.

23. Golbari NM, Porter ML, Kimball AB. Antiandrogen therapy with spironolactone for the treatment of hidradenitis suppurativa. J Am Acad Dermatol. 2019;80(1):114–119.

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.

27. Ingram JR, Woo PN, Chua SL, et al. Interventions for hidradenitis suppurativa. Cochrane Database Syst Rev. 2015;(10):CD010081.

28. Tzanetakou V, Kanni T, Giatrakou S, et al. Safety and efficacy of anakinra in severe hidradenitis suppurativa: a randomized clinical trial. JAMA Dermatol. 2016;152(1):52–59.

29. Riis PT, Boer J, Prens EP, et al. Intralesional triamcinolone for flares of hidradenitis suppurativa (HS): a case series. J Am Acad Dermatol. 2016;75(6):1151–1155.

30. Vossen AR, van Doorn MB, van der Zee HH, et al. Apremilast for moderate hidradenitis suppurativa: results of a randomized controlled trial. J Am Acad Dermatol. 2019;80(1):80–88.

31. Verdolini R, Clayton N, Smith A, et al. Metformin for the treatment of hidradenitis suppurativa: a little help along the way. J Eur Acad Dermatol Venereol. 2013;27(9):1101–1108.

32. Matusiak L, Bieniek A, Szepietowski JC. Acitretin treatment for hidradenitis suppurativa: a prospective series of 17 patients. Br J Dermatol. 2014;171(1):170–174.

33. Danby FW, Hazen PG, Boer J. New and traditional surgical approaches to hidradenitis suppurativa. J Am Acad Dermatol. 2015;73(5 suppl 1):S62–S65.

34. Kohorst JJ, Baum CL, Otley CC, et al. Surgical management of hidradenitis suppurativa: outcomes of 590 consecutive patients. Dermatol Surg. 2016;42(9):1030–1040.

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.

37. Mikkelsen PR, Dufour DN, Zarchi K, et al. Recurrence rate and patient satisfaction of CO2 laser evaporation of lesions in patients with hidradenitis suppurativa: a retrospective study. Dermatol Surg. 2015;41(2):255–260.

38. Van Rappard DC, Mekkes JR. Treatment of severe hidradenitis suppurativa with infliximab in combination with surgical interventions. Br J Dermatol. 2012;167(1):206–208.

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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