Intralesional corticosteroid injection for the treatment of hidradenitis suppurativa: a multicenter retrospective clinical study

Essentials of hidradenitis suppurativa: a comprehensive review of diagnostic and treatment perspectives

Hidradenitis suppurativa, or acne inversa, is a chronic inflammatory skin condition with recurrent inflammatory nodules, abscesses, subcutaneous tracts, and scars. This condition may cause severe psychological distress and reduce the quality of life for affected individuals. It is considered to have one of the most damaging effects on quality of life of any skin disorder as a result of the discomfort and foul-smelling discharge from these lesions. Although the pathophysiology of HS is still unclear, multiple factors, including lifestyle, genetic, and hormonal factors, have been associated with it. The pathogenesis of HS is very complex and has wide clinical manifestations; thus, it is quite challenging to manage and often requires the use of combination treatments that must be tailored according to disease severity and other patient-specific factors. Although lifestyle changes, weight loss, quitting smoking, topical treatments, and oral antibiotics are adequate for mild cases, the challenge for healthcare professionals is dealing with moderate-to-severe HS, which often does not respond well to traditional approaches. This literature review, consisting of an overview of the various assessment tools and therapy strategies available for the diagnosis and treatment of HS from published literature, aims to be a guide for practicing clinicians in dealing with the complexities associated with this disease.

Role of Color Doppler Ultrasound in Cutaneous Inflammatory Conditions

Inflammatory cutaneous diseases can be challenging to diagnose and manage. Nowadays, the anatomical information provided by ultrasound is critical for detecting subclinical alterations and assessing the severity and activity of these conditions. Many of these entities can be clinically observed in dermatology and other specialties, such as rheumatology, plastic surgery, ophthalmology, and otolaryngology, among others. We review the ultrasonographic patterns of the most common inflammatory cutaneous conditions. In several cases, such as hidradenitis suppurativa, acne, and morphea, there are ultrasonographic staging systems of severity or activity that are pivotal in the management of these diseases. The early ultrasonographic diagnosis of these entities implies a proper management of the patients and, therefore, improve their quality of life. Thus, knowledge of the current use of ultrasound in this field seems essential.

Topical and Intralesional Therapies for Hidradenitis Suppurativa: A Systematic Literature Review

BACKGROUND AND OBJECTIVE

Topical and intralesional (IL) treatments may be considered the first-line therapy in patients with hidradenitis suppurativa (HS); however, the evidence supporting their use is limited. The aim of our review is to evaluate the efficacy and safety profile of topical and IL treatments in patients with HS.

MATERIALS AND METHODS

We designed a systematic review of the current medical literature available following the PICO(T) method. And including all types of studies (Study type [T]) of individuals with HS of any sex, age, and ethnicity (Population [P]) who received any topical or IL treatment for HS (Intervention [I]) compared to placebo, other treatments, or no treatment at all (Comparator [C]), and reported efficacy and/or safety outcomes (Outcomes [O]). Two outcomes were defined: quality of life and the no. of patients with, at least, one adverse event. The search was conducted in the Cochrane Library, MEDLINE, and Embase databases; study selection was performed based on pre-defined criteria. The risk of bias was determined in each study.

RESULTS

We obtained a total of 11,363 references, 31 of which met the inclusion criteria. These studies included 1143 patients with HS, 62% of whom were women. A total of 10, 8, 6, 2, and 5 studies, respectively, evaluated the use of photodynamic therapy (PDT), glucocorticoids, resorcinol, topical antibiotics, and other interventions. Most articles were case series (n=25), with only five randomized clinical trials (RCTs) and one cohort study. RCTs showed improvement in disease activity with topical clindamycin and botulinum toxin (BTX) vs placebo, and PDT with methylene blue (MB) niosomal vs free MB; however, intralesional triamcinolone acetonide was not superior to placebo. The risk of bias was low in three RCTs and high in two RCTs.

CONCLUSION

The quality of evidence supporting the use of topical, or IL treatments is low. However, it supports the use of topical clindamycin, PDT, and BTX. Well-designed RCTs with standardized outcomes and homogeneous populations of patients and lesions are needed to support decision-making in the routine clinical practice.

Safety and Effectiveness of Percutaneous Ultrasound-Guided Galvanic Current in Tunnels of Patients with Hidradenitis Suppurativa: A Pilot Study

INTRODUCTION

The recurrent nature of hidradenitis suppurativa (HS), even under maintained systemic treatment, makes it necessary to have effective local treatments; however, the response to these therapies is variable (44-81%). The application of galvanic current (GC) has demonstrated its utility in humans in treating lesions structurally similar to those of HS. With this background, the main objective of this study was to evaluate the efficacy and safety of ultrasound-guided percutaneous GC in inflamed and/or draining tunnels of HS.

METHODS

This was an open study (one-way repeated measures design over time). Patients were evaluated at 4 and 12 weeks after receiving GC. A combined clinical response at week 12 (absence of suppuration/inflammation on examination and clinical interview) was considered the principal variable of efficacy. Adverse effects potentially associated with GC were reported by telephone and at each visit.

RESULTS

Twenty-six patients were included, with a male/female ratio of 5:8. The mean age was 35.84 (13.14) years. At 12 weeks after the administration of GC, a complete response was achieved in 77% (20/26) of the treated lesions. No serious adverse effects were observed, and the mean procedural pain assessed by the numeric rating scale was 0.03 (0.2).

CONCLUSION

GC has proven to be effective and well tolerated in inflamed and draining tunnels of patients with HS.

Topical and Intralesional Therapies for Hidradenitis Suppurativa: A Systematic Literature Review

BACKGROUND AND OBJECTIVE

Topical and intralesional (IL) treatments may be considered the first-line therapy in patients with hidradenitis suppurativa (HS); however, the evidence supporting their use is limited. The aim of our review is to evaluate the efficacy and safety profile of topical and IL treatments in patients with HS.

MATERIALS AND METHODS

We designed a systematic review of the current medical literature available following the PICO(T) method. And including all types of studies (Study type [T]) of individuals with HS of any sex, age, and ethnicity (Population [P]) who received any topical or IL treatment for HS (Intervention [I]) compared to placebo, other treatments, or no treatment at all (Comparator [C]), and reported efficacy and/or safety outcomes (Outcomes [O]). Two outcomes were defined: quality of life and the no. of patients with, at least, one adverse event. The search was conducted in the Cochrane Library, MEDLINE, and EMBASE databases; study selection was performed based on pre-defined criteria. The risk of bias was determined in each study.

RESULTS

We obtained a total of 11,363 references, 31 of which met the inclusion criteria. These studies included 1143 patients with HS, 62% of whom were women. A total of 10, 8, 6, 2, and 5 studies, respectively, evaluated the use of photodynamic therapy (PDT), glucocorticoids, resorcinol, topical antibiotics, and other interventions. Most articles were case series (n=25), with only five randomized clinical trials (RCTs) and one cohort study. RCTs showed improvement in disease activity with topical clindamycin and botulinum toxin (BTX) vs placebo, and PDT with methylene blue (MB) niosomal vs free MB; however, intralesional triamcinolone acetonide was not superior to placebo. The risk of bias was low in three RCTs and high in two RCTs.

CONCLUSION

The quality of evidence supporting the use of topical, or IL treatments is low. However, it supports the use of topical clindamycin, PDT, and BTX. Well-designed RCTs with standardized outcomes and homogeneous populations of patients and lesions are needed to support decision-making in the routine clinical practice.

Taiwanese Dermatological Association (TDA) consensus recommendations for the definition, classification, diagnosis, and management of hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory follicular disease characterized by painful, recurrent, inflamed lesions most commonly occurring in the axillary, inguinal, and anogenital regions. HS can inflict immense physical and psychological impact on patients who suffer from this distressing disease. Management of HS generally requires combining various medical and procedural treatment modalities; however, the disease is often recalcitrant to conventional treatments. In light of recent evidence supporting the effectiveness of biologic agents in the treatment of HS, the Taiwanese Dermatological Association established an expert panel of nine dermatologists to develop consensus statements aimed to provide up-to-date evidence-based guidance in optimizing HS patient management in Taiwan. The recommendations described in the statements were summarized in a management algorithm in terms of general care, topical treatment, systemic treatment, and procedural treatment.

Tolerability, acceptability, and reproducibility of topical STAR particles in human subjects

Topical delivery to treat dermatological disease is constrained by low skin permeability to most drugs due to the stratum corneum barrier. STAR particles containing microneedle protrusions can be topically applied on the skin to create micropores that dramatically increase skin permeability, even to water-soluble compounds and macromolecules. This study addresses the tolerability, acceptability, and reproducibility of STAR particles rubbed on the skin at multiple pressures and after multiple applications to human subjects. One-time STAR particle application at pressures between 40 and 80 kPa showed that skin microporation and erythema directly correlated with increased pressure, and 83% of subjects reported STAR particles to be comfortable at all pressures. Repeated application of STAR particles for 10 consecutive days at 80 kPa showed that skin microporation (~0.5% of skin area), erythema (low-to-moderate), and comfort with self-administration (75%) were similar over the course of the study. Comfort of sensations associated with STAR particles increased from 58% to 71% during the study, and familiarity with STAR particles increased from 12.5% to 50% of subjects reporting STAR particle application not feeling different from other skin products. This study demonstrates that topically applied STAR particles were well tolerated and highly acceptable after application at various pressures and repeated daily use. These findings further suggest that STAR particles offer a safe and reliable platform to enhance cutaneous drug delivery.

Practical Guidelines for Managing Patients With Hidradenitis Suppurativa: An Update

Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disease that is characterized by the formation of comedones, papules, nodules, abscesses and sinus tracts in the axillary, inframammary, groin, and gluteal areas. Up to 3.8% of the Canadian population has HS, though due to a lack of awareness of HS, many patients are initially misdiagnosed and do not receive adequate treatment early on in the disease course. Once a diagnosis of HS is made, developing an effective management plan can be a dilemma for many providers. There is significant variability in response to any given therapy within the HS patient population and many HS patients have other medical comorbidities which must be taken into consideration. The aim of this review is to provide a practical approach for all healthcare providers to diagnose and manage HS and its associated comorbidities. A sample electronic medical record template for HS management was developed by the Canadian Hidradenitis Suppurativa Foundation Executive Board and is intended for use in clinical settings. This will help to increase collaboration between primary healthcare providers, dermatologists, and other medical specialists and ultimately improve the quality of care that HS patients receive.

Medical Management of Hidradenitis Suppurativa with Non-Biologic Therapy: What's New?

Hidradenitis suppurativa (HS) is a severe chronic relapsing inflammatory disorder of the hair follicle unit that can cause painful abscesses, nodules, tunnels, and tracts in intertriginous parts of the body. The disease can often result in disfigurement and adversely impact patient quality of life. The management of HS has expanded significantly over the past decade to include multiple modalities, including topical therapies, systemic therapies (non-biologics and biologics), surgical therapies, lifestyle changes, and management of comorbidities. Management can often be clinically challenging and may involve the combination of medical and surgical approaches for optimal results. The purpose of this review is to present an update on non-biologic and non-interventional modalities published in 2019-2021 in the clinical management of HS. With emerging therapies, ongoing clinical trials, and heightened awareness about HS, there is hope that new treatment options will revolutionize the management of patients suffering from HS.

New perspectives on the treatment of hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease characterized by the presence of painful nodules, abscesses, chronically draining fistulas, and scarring in apocrine gland-bearing areas of the body. The exact pathogenesis of HS is not yet well understood, but there is a consensus in considering HS a multifactorial disease with a genetic predisposition, an inflammatory dysregulation, and an influence of environmental modifying factors. Therapeutic approach of HS is challenging due to the wide clinical manifestations of the disease and the complex pathogenesis. This review describes evidence for effectiveness of current and emerging HS therapies. Topical therapy, systemic treatments, biological agents, surgery, and light therapy have been used for HS with variable results. Adalimumab is the only US Food and Drug Administration (FDA) approved biologic agent for moderate-to-severe HS, but new therapeutic options are being studied, targeting different specific cytokines involved in HS pathogenesis. Comparing treatment outcomes between therapies is difficult due to the lack of randomized controlled trials. Treatment strategy should be selected in concordance to disease severity and requires combination of treatments in most cases.

Ultrasound-guided injection of intralesional steroids in acute hidradenitis suppurativa lesions: A prospective study

The management of hidradenitis suppurativa (HS) flares with intralesional steroids lacks strong scientific evidence but limited data suggest that it may be useful. The objective of this study is to assess the clinical and ultrasound responses of HS flares to ultrasound‐guided injections of intralesional triamcinolone (40 mg/ml) with a dilution 1:4 versus 1:2 at 30‐day (t1), 60‐day (t2), and 90‐day (t3) follow‐up. We recruited patients with ≤3 acute lesions, unresponsive to topical therapy. At baseline we assessed lesions clinically and by ultra‐high frequency ultrasound (48 or 70 MHz) and randomly performed an ultrasound‐guided injection of triamcinolone. Assessments were repeated at t1, t2, and t3 follow‐up, re‐injecting the lesion in the case of no or partial response. We treated 49 lesions: 38.8% showed improvements at t1; 46.9% at t2; 6% at t3; and 8.3% showed no clinical and ultrasound improvements. Long‐term follow‐up data confirmed a statistically significant reduction in Visual Analogue Scale (VAS)‐pain, Dermatology Life Quality Index (DLQI), and HS‐Physician Global Assessment (HS‐PGA), as well as edema and vascular signals. No adverse effects were reported. Our study suggests that ultrasound‐injections with a 1:2 dilution are beneficial for HS flares that do not respond to topical treatment and should be included in the therapeutic algorithm.

[Topical and novel device-based therapies for mild hidradenitis suppurativa]

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the skin folds, which requires more outpatient treatment alternatives. Although the disease was previously treated using surgery, new treatment modalities now allow the effective treatment of mild and moderate cases in an ambulatory care setting.

AIM OF STUDY

Local and instrument-based therapies are presented and their efficacy and safety profiles are highlighted.

MATERIALS AND METHODS

Clinical evidence for each therapeutic modality are presented and current treatment developments are analyzed based on the future treatment of HS patients in Germany.

RESULTS

Effective treatments for outpatient care of HS patients include topical clindamycin, resorcinol, and intralesional corticosteroids. New devices such as LAight therapy (combining intense pulsed light [IPL] with radiofrequency) are available, which can be used as monotherapy or adjunct therapy in combination with systemic treatment and/or surgery for the management of HS.

CONCLUSION

Evidence-based use of local treatments can provide more efficient outpatient and self-administered strategies, which improves the quality of life of HS patients, especially for patients with recurrent mild and moderate disease.

Ultrasound-assisted intralesional corticosteroid infiltrations for patients with hidradenitis suppurativa

Corticosteroid infiltrations of lesions in hidradenitis suppurativa (HS) appear to be beneficial to acute flares. The aim of this study is to evaluate the effectiveness and safety of ultrasound-assisted intralesional corticosteroid infiltrations to HS lesions. Prospective cohort study between February 2017 and February 2019 on patients with mild to severe HS and one or more inflammatory lesions. The study intervention was ultrasound-assisted intralesional infiltration of triamcinolone acetonide 40 mg/ml. The main outcome was the complete response rate of infiltrated lesions versus non-infiltrated lesions. Two hundred and forty-seven infiltrated inflammatory lesions and 172 non-infiltrated lesions were included. At week 12, 81.1% (30/37) of nodules, 72.0% (108/150) of abscesses and 53.33% (32/60) of draining fistulas presented complete response versus 69.1% (47/68), 54.3% (38/70) and 35.3% (12/34) respectively for the non-infiltrated lesions. The Hurley stage negatively correlated with complete response for abscesses and draining fistulas at - 0.17 (SD 0.06) p < 0.01 and - 0.30 (SD 0.13) p < 0.02 respectively. Ultrasound-assisted corticosteroid infiltration is a useful technique for the treatment of inflammatory HS lesions, with high and sustained response rates, especially for abscesses and small to medium-size simple draining fistulas. The likelihood of response correlates negatively with the Hurley stage.

Hidradenitis Suppurativa: Current Understanding of Pathogenic Mechanisms and Suggestion for Treatment Algorithm

Hidradenitis suppurativa is one of the most distressing dermatological conditions and has a significant negative impact on patients' quality of life. However, the exact pathogenic mechanisms remain incompletely understood and-therefore-efficient therapies are still lacking. The current manuscript focuses on new findings on its pathogenic mechanisms and aims to provide practical therapy recommendations.