Hidradenitis suppurativa in children and adolescents: a review of treatment options

Causal relationship between metabolic syndrome and hidradenitis suppurativa: A two-sample bidirectional Mendelian randomization study

Observational studies have suggested an association between metabolic syndrome (MetS) and hidradenitis suppurativa (HS), but whether this relationship is causal remains unclear. Elucidating the causal direction could provide insights into disease mechanisms and potential interventions. We performed bidirectional two-sample Mendelian randomization (MR) using summary statistics from genome-wide association studies (GWAS) of MetS and HS. For validation, we replicated the MetS analysis using data from an independent GWAS. We applied multiple MR methods, primarily inverse variance-weighted (IVW) regression, and conducted sensitivity analyses to assess heterogeneity and pleiotropy. The MR analysis demonstrated MetS causally increased HS risk (IVW odds ratio [OR], 1.428 [95% CI, 1.193-1.710]; p < 0.001), with consistent evidence from sensitivity analyses. However, HS did not appear to causally influence MetS risk (IVW OR, 1.008 [95% CI, 0.988-1.028]; p = 0.438). This study provides evidence that MetS causally increases the risk of developing HS. However, we found no evidence for a causal relationship in the reverse direction from HS to MetS. Further research is warranted to elucidate the mechanisms underlying the identified causal association between MetS and subsequent HS development.

Hidradenitis suppurativa in children and young adults: a retrospective cross-sectional observational study in the United Kingdom

BACKGROUND

Hidradenitis suppurativa (HS) in children and young adults (CYA) (<18 years) is uncommon. No previous observational studies have been carried out in a UK CYA HS population.

METHODS

This study was based on retrospective case note reviews of CYA HS patients attending tertiary-level care in the CYA HS service in a UK hospital. Patients <18 years old with a known diagnosis of HS were screened for inclusion. Exclusion criteria were those with less than one follow-up appointment.

RESULTS

Twenty-eight CYA HS patients were identified, with an M:F ratio of 1:8.3. Mean BMI was 25.2 (SD: 7.6). 17 (61%) of cases had a relevant family history. Long-term antibiotic monotherapy was the most common treatment initiated. Lymecycline was the most commonly prescribed antibiotic, accounting for 23 (56%) of the 41 courses prescribed. Additional treatments initiated included dual therapy with rifampicin and clindamycin, isotretinoin, and adalimumab, which were more commonly prescribed in patients with Hurley Stage II or III.

CONCLUSIONS

This group had a female predominance with an apparent strong genetic predisposition which is seen in other HS CYA cross-sectional research. Treatment was varied in this cohort, however long courses of antibiotics, including combined therapy with rifampicin and clindamycin, were the mainstay of treatment, similar to management in the adult population. This study therefore adds to the limited information on the demographics and management of the HS CYA population.

Hidradenitis Suppurativa in Children and Adolescents: An Update on Pharmacologic Treatment Options

Hidradenitis suppurativa (HS) is a chronic, recurrent, inflammatory skin condition that manifests as painful, deep-seated, inflamed nodules and abscesses in the axillary, groin, perianal, perineal, and inframammary regions. The associated pain, malodour, and disfigurement contribute to its profound negative impact on psychosocial spheres and overall quality of life in affected individuals. Although the symptoms of HS classically begin in the second or third decade of life, HS affects children and adolescents as well. Despite this, there are limited pediatric data on treatment, which are largely based on expert opinion, extrapolation of efficacy data in adults with HS, and safety information from medication use in other pediatric diseases. On this basis, there exist several pharmacological modalities in the treatment of children and adolescents with HS including topical therapies, systemic therapies, and biologics. The goals of this review article are to: (1) review the efficacy of different pharmacological treatment modalities in children and adolescents with HS, and (2) review the safety and monitoring considerations of the different treatment options in children and adolescents with HS.

A cross-sectional study of pediatric hidradenitis suppurativa and the value of the International Hidradenitis Suppurativa Severity Score System (IHS4) as a pediatric clinical trial inclusion criteria

BACKGROUND

Hidradenitis suppurativa (HS) often develops in pediatrics, but few interventional studies include pediatric patients.

OBJECTIVES

This dual analysis of a pediatric HS cohort and typical eligibility criteria in adult trials aims to identify potential patient characteristics and inclusion criteria for future pediatric HS studies.

METHODS

This cross-sectional and descriptive study is based on a prospectively collected data registry from an HS clinic. We also queried 125 HS studies from the Clinicaltrials.gov database and information from 61 interventional systemic HS drug trials was analyzed.

RESULTS

The mean abscess and inflammatory nodule (AN) count in 81 pediatric subjects was 2.3 compared to 5.0 in adults with majority being Hurley stage I (39.5%, 32/81) or II (55.6%, 45/81). Most clinical trials required patients to be Hurley stage II/III with AN count of ≥3.

CONCLUSION

When developing clinical trials for pediatric HS, it is imperative to consider how baseline characteristics impact recruitment and disease assessment. Frequently used eligibility criteria in adult trials may severely limit pediatric recruitment. Although our registry had a large adult sample size, the main limitation of this study was the relatively smaller pediatric sample size.

Hidradenitis Suppurativa in the Pediatric Population: An International, Multicenter, Retrospective, Cross-sectional Study of 481 Pediatric Patients

Importance

Hidradenitis suppurativa (HS) in pediatric patients has been understudied. Increased awareness and recognition of HS prevalence in children demand efforts to better understand this condition.

Objective

To describe the demographics, clinical features, treatment, associated comorbidities, and outcomes in a large cohort of pediatric patients with HS.

Design, Setting, and Participants

International, multicenter, retrospective medical record review of pediatric patients (aged 1-18 years) with a clinical diagnosis of HS carried out in 10 dermatology clinics across the US, Canada, Israel, Australia, and Italy from January 1996 to January 2017.

Main Outcomes and Measures

Patient demographics, clinical features, severity, associated comorbidities, and treatments in pediatric patients with HS.

Results

This cross-sectional study included 481 patients diagnosed with HS. Overall, 386 (80%) were girls. The mean (SD) age of disease onset was 12.5 (2.9) years, and the mean (SD) age at diagnosis was 14.4 (3.5) years. Family history of HS was present in 111 of 271 (41%) patients. First signs/symptoms reported at disease onset were cyst/abscess in 229 of 481 (48%), pain/tenderness in 118 of 481 (25%), and papules/pustules in 117 of 481 (24%). At initial dermatologic assessment, 233 of 481 (48%) patients already had evidence of skin scarring. Disease severity (Hurley staging) was documented in 288 of 481 (60%) patients (47% stage 1, 45% stage 2 and 8% stage 3). Comorbid conditions were reported in 406 of 481 (85%) patients, the most common being obesity (263/406 [65%]) and acne vulgaris (118/406 [29%]). Complications occurred in 378 of 481 (79%) patients, the most common of which were scars or contractures (301/378 [80%]).

Conclusions and Relevance

The findings of this study indicate that there is a gap in recognizing and diagnosing pediatric HS. Pediatric patients with HS are likely to present with other comorbidities. Prospective observational and interventional studies are needed to better understand clinical course and optimal treatments for pediatric HS.

Multidisciplinary Management of Adolescents with Hidradenitis Suppurativa - Series of Cases and Literature Review

Hidradenitis suppurativa (HS) is a recurrent chronic inflammatory condition of the skin with a debilitating potential, especially in adolescents who may experience psychosocial disorders and impaired quality of life. Recognition of typical, recurrent lesions, history of the disease and family investigation establishes the diagnosis. The rarity of the disease in males and the appearance of this condition in children, which is also rare, in two of our adolescent patients, respectively, are the reasons for publishing this article. We reviewed the literature and found that variation exists across international treatment for this HS, and much collaboration is needed to put forth unified and updated recommendations. It is of major importance that the early recognition of the condition and the establishment of treatment in the multidisciplinary team. Psychotherapy, health education, the adoption of a healthy lifestyle, the application of local prevention measures, and long-term medical treatment are components of a correct management. Extensive surgical treatment should be restricted only to severe cases because it may lead to complications, extend the hospitalization period and increase psychological problems in adolescents. The treatment will be personalized, performed according to the stage of evolution, and the approach will be a multidisciplinary one.

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Hidradenitis suppurativa; classification, remedies, etiology, and comorbidities; a narrative review

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that is more common in females, especially during puberty and menopause. These inflammatory lesions include painful deep-seated nodules and abscesses, draining sinus tracts, and fibrotic scars. This article is a narrative review to explain whole disease aspects, including complication, causes, epidemiology, history, classification, prognosis, comorbidities, the effect of sex hormone, and potent treatments. Most patients with HS, who are not aware of their primary disease, visit primary care physicians to superinfection lesions instead of specialists. If these physicians suspect HS, their illness will not get misdiagnosed. This brief and comprehensive information in this article may help doctors to decide better about the same situation.

Weight counseling in pediatric hidradenitis suppurativa patients

BACKGROUND/OBJECTIVES

Hidradenitis suppurativa is a chronic, painful, debilitating disease that may present in the pediatric years. Overweight and obesity are believed to worsen disease severity, but many patients do not receive counseling regarding weight control. The objective of this study is to examine the percentage of hidradenitis suppurativa patients who receive weight counseling as a part of their disease management and which specialties primarily care for these patients.

METHODS

We performed a retrospective chart review of pediatric hidradenitis suppurativa patients between January 2011 and October 2018. Demographic data, height, weight, body mass index, body mass index percentiles, number of visits per department, referrals to the Center for Healthy Weight and Nutrition, and referring provider department data were collected.

RESULTS

A total of 535 pediatric hidradenitis suppurativa patients were reviewed; 79.6% were female, and the mean age at diagnosis was 14.5 years. 11.6% of patients were overweight, and 54.2% were obese. 32.1% of overweight and obese hidradenitis suppurativa patients received a referral to the Center for Healthy Weight and Nutrition. The majority of referrals were placed by Primary Care. Dermatology placed 7.1% of the referrals to the Center for Healthy Weight and Nutrition for these patients.

CONCLUSIONS

The results suggest that there is a need for increased awareness, education, and counseling on weight management and nutrition for pediatric hidradenitis suppurativa patients. Further studies are needed to determine the success of counseling on weight control and disease severity.

Long-term safety of adalimumab for patients with moderate-to-severe hidradenitis suppurativa

Introduction: Hidradenitis suppurativa (HS) is a chronic debilitating inflammatory skin disorder that affects regions rich in apocrine glands. Although the etiology of HS is not clear, inflammatory cytokines, like tumor necrosis factor (TNF)-α, participate in pathogenesis. Adalimumab (ADA), a human IgG1 monoclonal antibody that selectively targets TNFα, is the only EMA/FDA-approved biologic agent available for the therapy of moderate-to-severe HS.Areas covered: A comprehensive literature search was conducted to present existing studies with an emphasis on the safety profile of ADA for the treatment of moderate-to-severe HS. ADA is prescribed for more than 15 years for varied indications and has improved the therapeutic outcomes of many diseases. Clinical trials and real-life safety data from ADA administration in HS were presented, with particular attention to special populations, such as children, elderly, and pregnant women.Expert opinion: Existing data advise for limited safety concerns with long-term ADA treatment provided that patients are thoroughly screened for infections, latent tuberculosis, and history of malignancy before the start of treatment.

Pediatric Endoscopic Hidradenitis Treatment: A New Minimally Invasive Treatment for Pediatric Patients with Hidradenitis Suppurativa

Background: Hidradenitis suppurativa (HS) is infrequent in the pediatric population. When indicated, surgery is often invasive, painful, and with significant recurrence rate. We aimed to report our preliminary experience using a new endoscopic technique to treat this pathology. Materials and Methods: We reported the data of 11 patients (9 girls and 2 boys) with average age of 15.7 years (range 14-17) with HS, who were operated using endoscopic procedure for a 15-month period. Six patients presented axillary, inguinal, and inframammary localizations, 3 patients presented axillary and inguinal localizations, and 2 patients presented only inguinal localization. Pediatric endoscopic hidradenitis treatment (PEHT) followed the same principles of pediatric endoscopic pilonidal sinus treatment (PEPSiT). The fistuloscope was introduced into the different holes, and after using an endobrush, all tracts were cauterized using monopolar electrode or laser energy, and finally the granulation tissues were removed using graspers. At the end of the procedure, all the holes were filled with oxygen-enriched oil-based gel and covered with fat gauze. Results: The average operative time was 47 minutes (range 30-80). All procedures were performed in a day surgery setting or with an overnight hospitalization. All patients reported no pain postoperatively and performed a local dressing with silver sulfadiazine spray and oxygen-enriched oil-based gel two times per day for 1 month postoperatively. At the longest follow-up of 1 year, the lesions were completely healed in all cases. Two patients (18%) developed further lesions in different untreated localizations that were successfully treated using PEHT. Conclusions: PEHT is a minimally invasive, effective, and safe treatment option for pediatric patients with HS. All patients reported a painless postoperative period and excellent results. Postoperative local dressings using oxygen-enriched oil-based gel and silver sulfadiazine spray are fundamental to achieve the complete healing. However, a further evidence with larger series and longer follow-up is required to confirm these preliminary results.

Management of adolescents with hidradenitis suppurativa

Hidradenitis suppurativa (HS) can have devastating impacts on quality of life (QoL), especially during adolescence when patients face unique challenges related to self-esteem, body-image, and sexual maturation. Many teenage HS patients also experience social challenges related to school, relationships, and employment that may require physician intervention. Strategies for comprehensive management of this special group include addressing low medication adherence, screening for comorbidities, and recommending practical lifestyle modifications to reduce disease flares. Herein, we review the impact of HS on adolescent patients and provide practical recommendations to minimize effects on the adolescent life course.

Surgical Management of Pediatric Hidradenitis Suppurativa: A Case Series and Review of the Literature

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic and physically debilitating condition. Achieving long-term remission is difficult and sometimes remains elusive despite use of multiple pharmacological agents. However, surgery remains underused in the pediatric population.

METHODS

We conducted a retrospective review for a 10-year period of all patients younger than 18 years who had undergone surgery for HS at a tertiary university hospital. In addition, we performed a literature review for English language articles related to the surgical management of pediatric HS patients.

RESULTS

Eleven patients with a total of 23 operative sites were included in the study. The cohort was predominantly female (10:1) with an average age of 15.4 years and mean body mass index 31.9 kg/m. Lesion size ranged from 12.6 to 400 cm. Overall complication rate was 87% with a 7% reoperation rate to manage complications. Remission was achieved after a single procedure in 57% of sites. Three articles met our inclusion criteria for the literature review.

CONCLUSIONS

Our article adds to the sparse literature and represents the largest study on surgical management of pediatric HS patients. Although surgery is not without its challenges, it presents a safe option and for pediatric HS patients with extensive scar or sinus tract formation.

Is There a Role for Antiandrogen Therapy for Hidradenitis Suppurativa? A Systematic Review of Published Data

BACKGROUND

Hidradenitis suppurativa/acne inversa is a disease with deep-seated chronic painful nodules, abscesses, and draining sinus tracts, which manifests on the apocrine gland-rich skin areas of the body. Observational findings demonstrate that the disease usually appears after puberty, exhibits pre-menstrual flares in women, improves in pregnancy, and worsens post-partum, which indicates a role of hormones and particularly of androgens in its pathophysiology. Because increased androgen levels in serum have not been widely reported, an end-organ androgen hypersensitivity has been postulated.

OBJECTIVE

The aim of this systematic review was to identify and present evidence for antiandrogen therapeutic options for the treatment of hidradenitis suppurativa/acne inversa.

METHODS

A literature search was conducted in different medical electronic databases using the keywords "hidradenitis", "suppurativa", "acne inversa", and "antiandrogen" on 1 December, 2018. The main therapeutic options were subsequently used as separate keywords with the disease terms in a separate search.

RESULTS

The main therapeutic options yielded were cyproterone acetate, spironolactone, finasteride, and metformin. One randomized controlled crossover trial and seven case series were identified following use of a standard extraction form for eligibility.

CONCLUSION

The existing studies do not allow a robust evidence-based recommendation for the use of antiandrogens in the treatment of hidradenitis suppurativa/acne inversa. Further randomized controlled trials are needed to define the role of hormonal treatment as an alternative or concomitant therapy together with antibiotics or biologics.

North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations: Part II: Topical, intralesional, and systemic medical management

Hidradenitis suppurativa is a severe and debilitating dermatologic disease. Clinical management is challenging and consists of both medical and surgical approaches, which must often be combined for best outcomes. Therapeutic approaches have evolved rapidly in the last decade and include the use of topical therapies, systemic antibiotics, hormonal therapies, and a wide range of immunomodulating medications. An evidence-based guideline is presented to support health care practitioners as they select optimal medical management strategies and is reviewed in this second part of the management guidelines. A therapeutic algorithm informed by the evidence available at the time of the review is provided.

Consensus on the treatment of hidradenitis suppurativa - Brazilian Society of Dermatology

Hidradenitis suppurativa is a chronic immune mediated disease of universal distribution that causes great damage to the quality of life of the affected individual, whose prevalence is estimated at 0.41% in the Brazilian population. The objective of this work was update on physiopathogenesis, diagnosis and classification of hidradenitis suppurativa and to establish therapeutic recommendations in the Brazilian reality. It was organized as a work group composed of eight dermatologists from several institutions of the country with experience in the treatment of hidradenitis suppurativa and carried out review on the topic. Recommendations were elaborated and voted by modified Delphi system and statistical analysis of the results was performed. The Brazilian consensus on the clinical approach of hidradenitis suppurativa had the support of the Brazilian Society of Dermatology.

Association Between Hidradenitis Suppurativa and Metabolic Syndrome: A Systematic Review and Meta-analysis

BACKGROUND

Recent studies have shown a relationship between hidradenitis suppurativa (HS) and metabolic syndrome (MS), but the literature offers no meta-analysis restricted to studies that have been adjusted for confounders.

OBJECTIVE

To determine the association between HS and MS.

METHODS

A systematic review and meta-analysis of observational studies on HS and MS in adults. We searched MEDLINE, SCOPUS, SCIELO, Google Scholar, Science Direct, and LILACS from the inception of the databases to January 2016. We performed a random effects model meta-analysis for studies reporting adjusted and crude odds ratios (ORs) with 95% CIs. A subgroup analysis was related to the type of HS patient (general patients vs hospital patients) and age group (adults vs children and adults).

RESULTS

Five studies including 3950 HS patients were analyzed. We found that MS was pres-ent in 9.64% of HS patients (OR, 1.82; 95%, CI 1.39-2.25). Studies from tertiary care hospital dermatology clinics (OR, 2.82; 95% CI, 0.58-5.06) reported a greater risk for MS than studies carried out in patients treated outside hospitals (OR, 1.78; 95% CI, 1.34-2.22). Studies that included pediatric populations reported a significant association (OR, 2.10; 95% CI, 1.58-2.62).

LIMITATION

Few of the included studies reported adjusted ORs.

CONCLUSIONS

HS patients have an increased risk for MS. Clinicians should consider screening HS patients for metabolic risk factors.

Long-Term Outcome of Adalimumab in a Young Girl with Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic, burdensome inflammatory skin disorder mainly affecting adults with an infrequent onset during childhood or adolescence. Guidelines regarding the therapeutic drugs in pediatric HS patients are lacking. We describe the case of a 16-year-old girl affected by HS with a massive impact of the disease on her daily activities. She underwent antibiotics, estroprogestinics, isotretinoin, and drainage procedures with partial and short-term improvement. We treated the patient with adalimumab and assessed disease severity using BMI, pain VAS, Hurley, m-Sartorius, and HS-PGA. The treatment has been continued for 4 years with a strong improvement of clinical and psychological outcome. No side effects were recorded throughout the treatment period.

Hidradenitis Suppurativa in Children Treated with Finasteride-A Case Series

BACKGROUND

Hidradenitis suppurativa (HS) is rare in childhood, with only 2% of cases in patients younger than 11 years. It is a chronic, recurrent, debilitating condition for which no universally effective treatment has been developed. We present five cases of children with HS diagnosed between the ages of 6 and 11 years.

METHODS

Patients were treated with oral finasteride 1 to 5 mg/day. All had entered puberty at the time of treatment initiation. All had normal laboratory results before starting treatment. The maximum duration of treatment was 24 months.

RESULTS

Four patients were female. Two were overweight. Three had been previously treated with oral antibiotics, and two of these with oral isotretinoin, with partial or no improvement. Overall improvement of the disease was observed in all patients, with a reduction of the frequency and intensity of the flares. No adverse effects were observed or reported during treatment.

CONCLUSION

Treatment of HS can be challenging. The options available include antimicrobials, immunosuppressants, hormonal therapies, lasers, and surgery. The authors report the largest series of children with HS treated with finasteride. The results support the use of finasteride as monotherapy for the treatment of this disease in children. Further studies are necessary to fully understand the role of this drug in the management of this disease.

Evidence-based approach to the treatment of hidradenitis suppurativa/acne inversa, based on the European guidelines for hidradenitis suppurativa

Hidradenitis suppurativa/acne inversa (HS) is a chronic inflammatory skin disease characterized by painful, recurrent nodules and abscesses that rupture and lead to sinus tracts and scarring. To date, an evidence-based therapeutic approach has not been the standard of care and this is likely due to the lack of evidence based treatment guidelines. The purpose of this study was to promote a holistic evidence-based approach which implemented Level of Evidence and Strength of Recommendation for the treatment of HS. Based upon the European Dermatology Forumguidelines for the management of HS, evidence-based approach was explored for the treatment of HS. The diagnosis of HS should be made by a dermatologist or other healthcare professional with expert knowledge in HS. All patients should be offered adjuvant therapy as needed (pain management, weight loss, tobacco cessation, treatment of super infections, and application of appropriate dressings). The treating physician should be familiar with disease severity scores, especially Hurley staging, physician global assessment and others. The routine use of patient'reported outcomesincluding DLQI, itch and pain assessment (Visual Analogue Scale) is strongly recommended. The need for surgical intervention should be assessed in all patients depending upon type and extent of scarring, and an evidence-based surgical approach should be implemented. Evidence-based medical treatment of mild disease consists of topical Clindamycin 1 % solution/gel b.i.d. for 12 weeks or Tetracycline 500 p.o. b.i.d. for 4 months (LOE IIb, SOR B), for more widespread disease. If patient fails to exhibit response to treatment or for a PGA of moderate-to-severe disease, Clindamycin 300 p.o. b.i.d. with Rifampicin 600 p.o. o.d. for 10 weeks (LOE III, SOR C) should be considered. If patient is not improved, then Adalimumab 160 mg at week 0, 80 mg at week 2; then 40 mg subcutaneously weekly should be administered (LOE Ib, SOR A). If improvement occurs then therapy should be maintained as long as HS lesions are present. If the patient fails to exhibit response, then consideration of second or third line therapy is required. A growing body of evidence is being published to guide the treatment of HS. HS therapy should be based upon the evaluation of the inflammatory components as well as the scarring and should be directed by evidence-based guidelines. Treatment should include surgery as well as medical treatment. Future studies should include benefit risk ratio analysis and long term assessment of efficacy and safety, in order to facilitate long term evidence based treatment and rational pharmacotherapy.

Current concepts in the management of hidradenitis suppurativa in children

PURPOSE OF REVIEW

This review is intended to provide the background aetiopathogenetic framework upon which management of this disorder can be based, particularly with relation to new concepts of the pathogenesis of the disorder. The emphasis is on the prevention of the disorder's full expression by addressing the metabolic changes that drive the underlying structural damage and the immune system's subsequent reaction to this damage.

RECENT FINDINGS

The mechanism by which dietary factors impact on this disease are elucidated, the anatomic defect suspected to be responsible for the disorder is introduced, and an updated flow sheet describing and linking the clinicopathological changes recently described are provided.

SUMMARY

Recent work in the understanding of the induction and evolution of the lesions provides a background upon which the preventive regimen and both the medical and surgical approaches can be effectively based.

Hidradenitis Suppurativa in prepubescent and pubescent children

Hidradenitis Suppurativa (HS) is an uncommon disease, which is particularly rare in young and prepubescent children. HS pathology centers on the follicular unit and involves aberrant cutaneous cellular immunity. HS tends to first manifest in puberty, but a handful of prepubescent cases of HS have been reported and are linked to hormonal disorders, in particular elevated testosterone. The most common manifestations of HS are abscesses, scarring, acne inversa, and keloids, especially in the intertriginous areas of the groin and the axilla. Treatments including topical anti-infectives including chlorhexidine wash, topical clindamycin, tretinoin cream, and azelaic acid cream, which may be of limited use because bacteria involved in HS likely create biofilms. Oral agents include clindamycin with or without rifampin for short-term usage. Cases resistant to conservative therapy have been reported to respond to finasteride, onabotulinumtoxin, or microfractionated 10,600-nm CO2 laser.