Hidradenitis suppurativa is a rather nasty, if not downright heinous and obnoxious, skin infection. Even part-time clinicians know how often these malicious skin infections populate the ED.
Emergency physicians are generally aware of mild to moderate cases of HS, consisting of small papules, pustules, or frank boils of the axilla or groin. Those afflicted with HS are unfortunate indeed, especially if their condition is more than an occasional small abscess that is easily drained.
HS is more than a series of recurring abscesses. It's actually a chronic skin condition that is characterized by nodules, sinus tracts, recurring abscesses, and painful deep-seated fibrosis and scars. The emergency physician sees only the acute abscess phase of HS, and often can provide at least temporary relief, but the surgeon or dermatologist is the specialist who should be providing more definitive long-term care. HS is not life-threatening, but it clearly has an adverse effect on quality of life.
Clinical Practice. Hidradenitis Suppurativa
New Engl J Med
This informative article is well worth reading, and it includes a presentation of a patient with a typically complicated case of HS. It includes pathogenesis, treatment, and overall clinical recommendations as well as a number of well done images.
The author, a dermatologist from Denmark, described a 36-year-old woman with recurrent boils under both arms and in the groin. She had experienced recurrent flares with pain, pus-filled nodules, and an offensive odor. She developed significant scars and had chronically draining sinus tracts because of the chronic and recurrent condition. Repetitive I&D of discrete abscesses peppered with multiple courses of antibiotics made little headway in curing this unfortunate woman. It goes without saying that this patient has a miserable and wretched condition that not only caused her great discomfort, but was also embarrassing, eventually socially isolating her.
HS is a chronic, recurring inflammatory disease, affecting skin with apocrine glands or hair follicles, usually of the axilla or groin. It is manifested as painful, deep-seated inflamed lesions, including nodules, sinus tracts, fibrosis, and abscesses. It is a disease of young adults and may affect up to four percent of the population. Women are more frequently affected than men (3:1), first manifesting itself around the early 20s. HS has a familial incidence, and is chromosome-linked (autosomal dominant). About a third of those affected report a family history of HS. Well known risk factors are cigarette smoking and obesity, but it is not associated with such common clinical felons as diabetes, AIDS, or other forms of immunocompromise. A delay in making the definitive diagnosis is common because the disease is often mistaken for simple recurrent boils. Signs of multiple previous foci of infection, however, clinch the diagnosis.
The exact pathogenesis of HS is unclear, but it is a problem with hair follicles and sebaceous glands, whose acute and chronic inflammation results in scarring and granuloma and sinus tract formation. It may be an immune disorder. Flares are associated with bacterial infections, and cultures are frequently negative and of little clinical help. Contrary to common thinking, HS is not primarily a bacterial-initiated cutaneous abscess.
The Hurley staging system describes the various intensities of the condition. The first stage consists of single or multiple abscesses, without scarring or sinus tracts. The most advanced form demonstrates diffuse involvement of the affected area, with multiple interconnected tracts, draining sinuses, scarring, fibrosis, and multiple abscesses of varying size.
A variety of medical treatments for HS have been tried with varying but limited success. Topical antibiotic preparations, long-term suppressive antibiotic therapy, and immunosuppressive agents have all been studied. Lasers, radiation therapy, antiandrogens, intralesional steroids, and immunosuppressive medications are also occasionally used. None of these often-tried interventions is conclusively recommended because of insufficient data.
Most physicians are familiar with a garden-variety fast track or ED-initiated I&D of discrete boils, often with antibiotic coverage. But this only provides a temporary respite, and although intuitive, it may be counterproductive in the long run. Avoidance of I&D is supported for all but the most obvious pus-filled abscess.
Surgery provides the best chance for cure in advanced cases, and surgical interventions can be quite radical. The cornucopia of sinus tracts, scars, fibrosis, and recurrent boils create permanent disability. Widespread aggressive surgical excision is the final pathway for some. Interventions include excision of scar tissue, unroofing and exteriorization of sinus tracts, and block removal of scar tissue.
This author suggests topical clindamycin as an initial treatment for mild disease, coupled with long-term antibiotic therapy (about four to six months) for more advanced cases. This author does not believe that abscess culturing provides useful information.
Comment: Interestingly, this article states that no formal guidelines are currently available for managing hidradenitis suppurativa. There appears to be a consensus for avoiding routine I&D of discrete abscesses in the ED because it is not curative and can enhance scarring. In my mind, a true pus-packed boil in the axilla is a boil that needs to be drained. I never considered that I&D might worsen scarring and dysfunction. It is difficult to avoid draining pus in any area, but in this disease, intuitive I&D exacerbates the underlying process. Some abscesses just beg to be drained, and while it's best not to manipulate small lesions, I would I&D a large discrete abscess. It seems to me that loop drainage was made for this type of abscess. The loop drains pus and avoids wide or deep incisions.
I have never personally tried topical clindamycin, but patients frequently ask for some local prophylactic intervention. I will now start prescribing long-term topical clindamycin (1% gel, lotion, or suspension, BID) to patients with recurrent HS. This is right out of the acne treatment playbook, and it's a popular recommendation for HS. This author suggests doxycycline 100 BID for about four to six months or a combination of clindamycin and rifampin for long-term antibiotic treatment. I think it best to get such patients into the hands of a specialist.
Pathogenesis and Pharmacology of Hidradenitis Suppurativa
Nazary M, van der Zee HH, et al
Eur J Pharmacol
This author believes that HS is not a problem isolated to apocrine sweat glands, but is also a problem with hair follicles. Currently the most accepted hypothesis concerning the primary event of HS is occlusion of the terminal hair follicles or sweat glands as a result of hyperkeratinization. This leads to occlusion and dilation of the hair follicles, followed by rupture, infection, and formation of sinus tracts and fistulas.
HS appears to be an obvious infectious disease to the emergency physician, but bacterial infection is from skin flora, and long-term colonization is considered a secondary pathogenic factor. Staphylococci and streptococci are frequently isolated from abscesses or draining sinuses, but their role as an initiating pathogen is uncertain.
The beneficial role of anti-inflammatory drugs for HS supports an aberrant immune system as an underlying cause. This article also discusses treatment with such things as immunosuppressants, retinoids, or TNF inhibitors.
Comment: It's clear that HS is a complex disease, a condition much more confusing than one might originally intuit. It's not just recurrent abscesses of sweat glands but a miserable and progressive chronic inflammatory process that has no known specific etiology and no easy or ready cure. It seems to me that it's reasonable to drain fluctuant boils in the ED, and I know that gives at least temporary relief. I suggest providing long-term topical clindamycin for interim therapy, and perhaps three to four weeks of oral antibiotic therapy if the area looks chronically inflamed or infected. Cultures are likely of no value, according to most recommendations.
Looking for a cure from the ED is wishful thinking. It seems reasonable to recommend preventive measures such as avoiding skin trauma, frequent gentle bathing, loose clothing, and not roughing up the skin; some also suggest using antiperspirants. I have been telling patients not to shave under their arms, but that may not be necessary, and it is not stressed in the literature. Smoking cessation and weight management are nearly impossible for most patients to accomplish.
Bacterial infection is considered a secondary event in HS rather than the cause of the disease. It is frequently given and transiently helpful, but no evidence suggests that long-term antibiotic therapy alters the natural history of HS. It's worth trying and patients may have some initial success, but relapses are common after therapy is discontinuation of therapy. UpToDate.com says repeated I&D is not an effective or appropriate method for managing recurrent HS because it does not cure the disease. Topical 1% clindamycin is an ED intervention that is rarely considered, but one worth emphasizing. (Int J Dermatol 1983;22:325.)
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Dr. Roberts: I am second to none in my admiration for you and your InFocus column. In fact, I have saved every one since you began writing them. The abscess drainage column was excellent as always. (EMN 2013;35:20; http://bit.ly/YbHebv.) I do have a couple of comments. My rule for abscesses is if it is deeper than it is wide, then I put a small pack in it. This would prevent it from closing up early and reforming. My next rule is to use iodoform gauze, though not in the hand or foot because it causes tendonitis. — Mel Otten, MD, Cincinnati, OH
Dr. Roberts responds: Well spoken and sage advice, Dr. Otten. I think you learned that from Dr. Osler himself, or was it Hippocrates?
Current Approach to Abscesses Associated with Hidradenitis Suppurativa
Routine I&D for Hidradenitis Suppurativa?
These current recommendations from UpToDate.com focus on the philosophy of providing traditional I&D for an abscess of HS. I&D of a cutaneous abscess is generally considered definitive therapy, but HS is a process more complex than a simple cutaneous abscess.
- Incision and drainage of individual nodules provides only short-term relief and generally should be avoided. Lesions treated in this manner tend to recur with no long-term benefit.
- I&D is performed only for relieving pain in the setting of a tense abscess that is too painful to bear. The lesion must be deeply incised under local anesthesia. Packing the wound for a few days may be needed to prevent premature superficial closure while the wound fills in from below.
- I&D does not cure HS, and other therapies to control the disease are indicated. Repeated I&D is not an effective or appropriate method of managing HS.
- Punch debridement over I&D for acute inflammatory nodules may be preferred to I&D.
Source: www.UpToDate.com, Wolters Kluwer Health. Feb. 1, 2013.
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