Management of hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a skin disease that affects predominately apocrine gland‐bearing skin. The absence of a confirmatory test or specific features can make an early diagnosis difficult. It is characterized by deep abscesses, which are recurrent, sinus tract formation and scarring in more advanced disease. Disease activity is usually remarkably symmetrical with axillae and ano‐genital regions affected most often. Other sites, breasts, nape of neck and waistband, become involved as the condition progresses. Sinus tract formation has been designated the hallmark feature. Early pathology shows follicular occlusion, not apocrinitis, and therefore HS is best considered an inflammatory disease originating from the hair follicle. Current treatment is derived mainly from empirical attempts to control the disease. Anti‐acne antibiotics such as tetracyclines or macrolides are recommended. Only topical clindamycin has been shown to have an effect in a randomized controlled trial (RCT). More severe disease may demand oral clindamycin. If specific pathogens such as anaerobes are isolated then an appropriate antibiotic can be selected. Hormonal therapy with cyproterone acetate and ethinyloestradiol proved effective in one RCT but doses were high and continued use raises safety concerns. Steroid therapy has its advocates but a common experience is an initial response followed by relapse. Intra‐lesional steroids can be useful for localized disease. Other immunosuppressive agents such as cyclosporin have been reported to be of help. Retinoids would be expected to be helpful based on the relationship between HS and acne but isotretinoin appears unhelpful; acitretin seems better. Success with surgery is proportional to the radicality of surgery. Incision and drainage carries a recurrence rate of 100% while radical excision has a recurrence rate of 25% at a median interval of 20 months. Careful laying open of sinus tracks is seen by many as the best compromise.