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Włodarek K, Ponikowska M, Matusiak Ł, Szepietowski JC. Biologics for hidradenitis suppurativa: an update. Immunotherapy 2019; 11:45-59. [PMID: 30702012 DOI: 10.2217/imt-2018-0090] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Hidradenitis suppurativa (HS) is a chronic, inflammatory dermatosis characterized by an occurrence of nodules, abscesses, sinus tracks and scarring. Its pathogenesis is multifactorial and still not fully understood, therefore, current systemic therapies still remain a serious challenge. Increased levels of several proinflammatory cytokines have been reported in patients suffering from HS, therefore biologics appear as a new approach to therapy for this condition. Adalimumab is the only one internationally registered agent and should be considered first after the conventional therapies appear insufficient. The efficacy and safety profile of some preparations, like infliximab and etanercept was confirmed so far in randomized trials, but there are some new biologics which are still being evaluated and require more rigorous examination.
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Affiliation(s)
- Katarzyna Włodarek
- Department of Dermatology, Venereology & Allergology, Medical University, Wroclaw, Poland
| | - Małgorzata Ponikowska
- Department of Dermatology, Venereology & Allergology, Medical University, Wroclaw, Poland
| | - Łukasz Matusiak
- Department of Dermatology, Venereology & Allergology, Medical University, Wroclaw, Poland
| | - Jacek C Szepietowski
- Department of Dermatology, Venereology & Allergology, Medical University, Wroclaw, Poland
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Alikhan A, Sayed C, Alavi A, Alhusayen R, Brassard A, Burkhart C, Crowell K, Eisen DB, Gottlieb AB, Hamzavi I, Hazen PG, Jaleel T, Kimball AB, Kirby J, Lowes MA, Micheletti R, Miller A, Naik HB, Orgill D, Poulin Y. 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. J Am Acad Dermatol 2019; 81:91-101. [PMID: 30872149 PMCID: PMC9131892 DOI: 10.1016/j.jaad.2019.02.068] [Citation(s) in RCA: 179] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 02/21/2019] [Accepted: 02/27/2019] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
| | - Christopher Sayed
- Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Afsaneh Alavi
- Department of Medicine, Division of Dermatology, University of Toronto, Toronto, Ontario, Canada
| | - Raed Alhusayen
- Department of Medicine, Division of Dermatology, University of Toronto, Toronto, Ontario, Canada
| | - Alain Brassard
- Department of Dermatology, University of California at Davis, Sacramento, California
| | - Craig Burkhart
- Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Karen Crowell
- Health Sciences Library, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Daniel B Eisen
- Department of Dermatology, University of California at Davis, Sacramento, California
| | - Alice B Gottlieb
- Department of Dermatology, Icahn School of Medicine at Mt Sinai Hospital, New York, New York
| | - Iltefat Hamzavi
- Department of Dermatology, Henry Ford Hospital, Detroit, Michigan
| | | | - Tara Jaleel
- Department of Dermatology, Duke University School of Medicine, Durham, North Carolina
| | - Alexa B Kimball
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
| | - Joslyn Kirby
- Department of Dermatology, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | | | - Robert Micheletti
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Angela Miller
- Department of Dermatology, Henry Ford Hospital, Detroit, Michigan
| | - Haley B Naik
- Department of Dermatology, University of California San Francisco, San Francisco, California
| | - Dennis Orgill
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Yves Poulin
- Centre de Recherche Dermatologique du Quebec Metropolitain, Quebec City, Quebec, Canada
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Lim SYD, Oon HH. Systematic review of immunomodulatory therapies for hidradenitis suppurativa. Biologics 2019; 13:53-78. [PMID: 31190730 PMCID: PMC6526329 DOI: 10.2147/btt.s199862] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 03/22/2019] [Indexed: 12/21/2022]
Abstract
Background: Greater understanding of the roles of tumor necrosis factor-α, IL-1β, IL-10, and the IL-23/T-helper (Th) 17 and IL-12/Th1 pathways in immune dysregulation in moderate/severe hidradenitis suppurativa (HS) has helped in developing new regimens. We aim to review the use of different immunomodulatory therapies used to manage HS. Methods: A comprehensive literature search was conducted on the PubMed and Clinicaltrials.gov databases from 1 January 1947 to 31 December 2018. Only clinical trials, case reports, case series and retrospective analyses published in the English language were included. Results: Our search yielded 107 articles and 35 clinical trials, of which 15 are still ongoing. The tumor necrosis factor-α inhibitors adalimumab and infliximab were the most comprehensively studied agents. Published data from clinical trials support the efficacy of adalimumab, infliximab, anakinra, ustekinumab, bermekimab and apremilast but not etanercept and MEDI8968. Clinical trials for CJM112 have been completed, with results awaiting publication. Trials are underway for secukinumab, IFX-1, INCB054707 and bimekizumab. Biologics used in smaller cohorts include canakinumab, golimumab and rituximab. Most agents are well tolerated and demonstrate a good safety profile, with the most commonly reported adverse event being infections. Discussion and conclusions: To date, adalimumab is the only biologic which has been approved by the United States Food and Drug Administration for HS. However, other agents also show promise, with further trials underway to evaluate their efficacy, tolerability and safety profiles. Different clinical measurement scores and endpoints used to make direct comparison difficult. Longitudinal surveillance and pooled registry data are paramount to evaluate the long-term safety profile and efficacy of therapy.
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Affiliation(s)
- Shi Yu Derek Lim
- Internal Medicine Residency, National Healthcare Group, Singapore, Singapore
| | - Hazel H Oon
- Department of Dermatology, National Skin Centre, Singapore, Singapore
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Smith MK, Nicholson CL, Parks-Miller A, Hamzavi IH. Hidradenitis suppurativa: an update on connecting the tracts. F1000Res 2017; 6:1272. [PMID: 28794864 PMCID: PMC5538037 DOI: 10.12688/f1000research.11337.1] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2017] [Indexed: 12/18/2022] Open
Abstract
Hidradenitis suppurativa (HS) is a devastating disease involving abscesses, sinus tracts, and inflammation classically affecting the axilla, groin, and/or anogenital region. Although the disease pathogenesis is not fully understood, recent advances suggest that HS pathology runs much deeper than the cutaneous manifestations. It is now believed that HS is a systemic inflammatory disease that gives rise to the characteristic cutaneous manifestations. This disease is problematic for both patients and physicians to manage because of a variety of diagnostic and management difficulties. This article seeks to provide updates on the current understanding of HS to increase awareness and improve management.
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Robert E, Bodin F, Paul C, Konstantinou MP, Gall Y, Grolleau JL, Laloze J, Chaput B. Non-surgical treatments for hidradenitis suppurativa: A systematic review. ANN CHIR PLAST ESTH 2017; 62:274-294. [PMID: 28457725 DOI: 10.1016/j.anplas.2017.03.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 03/28/2017] [Indexed: 01/24/2023]
Abstract
INTRODUCTION The management of hidradenitis suppurativa is multidisciplinary, involving general measures, medical treatment and surgery. Non-surgical treatments, often first-line procedures, mainly concern forms of low-to-moderate severity or, conversely, very severe forms in non-operable patients or those refusing surgery. While many treatments have been attempted, few randomized controlled trials have been conducted, so the choice of treatments is most often based on the personal experience of the clinicians. The objective of this systematic review is to propose a synthetic analysis of the currently available non-surgical procedures. METHODS This systematic review of the literature was conducted in accordance with the PRISMA criteria. We searched for articles in the Medline®, PubMed Central, Embase and Cochrane databases published between January 2005 and September 2015. RESULTS Sixty-four articles were included. They generally had a low level of evidence; indeed, the majority of them were retrospective observational studies. They involved biotherapy (44%), dynamic phototherapy (16%), antibiotics (11%), Laser (8%), retinoids (6%) and immunosuppressive therapies, anti-inflammatory drugs, zinc, metformin, gammaglobulins and fumarates. CONCLUSIONS None of the non-surgical treatments can treat all stages of the disease and offer long-term remission. Antibiotics and biotherapy seem to have real effectiveness but their effect remains suspensive and the disease is almost certain to reappear once they are stopped. As regards antibiotics, no association has shown their superiority in a study with a high level of evidence. And while some biotherapies seem quite effective, due to their side effects they should be reserved for moderate-to-severe, resistant or inoperable forms of the disease. Randomized controlled studies are needed before valid conclusions can be drawn. In the resistant or disabling forms, it is consequently advisable to orientate to the greatest possible extent towards radical surgery, which is the only treatment allowing hope for cure.
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Affiliation(s)
- E Robert
- Department of plastic surgery, Strasbourg university hospitals, university of Strasbourg, 67091 Strasbourg, France
| | - F Bodin
- Department of plastic surgery, Strasbourg university hospitals, university of Strasbourg, 67091 Strasbourg, France
| | - C Paul
- Department of dermatology, Rangueil-Larrey hospital, Paul-Sabatier university, 31059 Toulouse, France
| | - M-P Konstantinou
- Department of dermatology, Rangueil-Larrey hospital, Paul-Sabatier university, 31059 Toulouse, France
| | - Y Gall
- Department of dermatology, Rangueil-Larrey hospital, Paul-Sabatier university, 31059 Toulouse, France
| | - J-L Grolleau
- Department of plastic, reconstructive and aesthetic surgery, Rangueil hospital, 1, avenue Jean-Poulhès, 31059 Toulouse, France
| | - J Laloze
- Department of plastic, reconstructive and aesthetic surgery, Rangueil hospital, 1, avenue Jean-Poulhès, 31059 Toulouse, France
| | - B Chaput
- Department of plastic, reconstructive and aesthetic surgery, Rangueil hospital, 1, avenue Jean-Poulhès, 31059 Toulouse, France.
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Napolitano M, Megna M, Timoshchuk EA, Patruno C, Balato N, Fabbrocini G, Monfrecola G. Hidradenitis suppurativa: from pathogenesis to diagnosis and treatment. Clin Cosmet Investig Dermatol 2017; 10:105-115. [PMID: 28458570 PMCID: PMC5402905 DOI: 10.2147/ccid.s111019] [Citation(s) in RCA: 129] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease primarily affecting apocrine gland-rich areas of the body and presenting with painful nodules, abscesses, sinus tracts, and scarring. HS is a multifactorial disease in which genetic and environmental factors play a key role. The primary defect in HS pathophysiology involves follicular occlusion of the folliculopilosebaceous unit, followed by follicular rupture, and immune responses (perifollicular lympho-histiocytic inflammation), finally leading to the development of clinical HS lesions. HS has a destructive impact on the patient’s quality of life, being a very challenging disease. Available treatments are limited, mostly off-label and with high variability in the reported efficacy. Fortunately, a monoclonal antibody against tumor necrosis factor alpha has been recently approved for treatment of moderate to severe HS, offering patients a promising new option. This review focuses on the main features of HS, including epidemiology, clinical aspects, pathogenesis, severity classifications, comorbidities, and currently available treatments.
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Affiliation(s)
- Maddalena Napolitano
- Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio", Università degli Studi del Molise, Campobasso
| | - Matteo Megna
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Elena A Timoshchuk
- Department of Dermatovenereology, Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russia
| | - Cataldo Patruno
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Nicola Balato
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Gabriella Fabbrocini
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Giuseppe Monfrecola
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
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Scuderi N, Monfrecola A, Dessy LA, Fabbrocini G, Megna M, Monfrecola G. Medical and Surgical Treatment of Hidradenitis Suppurativa: A Review. Skin Appendage Disord 2017; 3:95-110. [PMID: 28560220 DOI: 10.1159/000462979] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 02/10/2017] [Indexed: 12/27/2022] Open
Abstract
Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease presenting with painful nodules, abscesses, sinus tracts, and scarring primarily affecting apocrine gland-rich intertriginous areas. HS prevalence ranges from 0.05 to 1%. The central pathogenic event in HS is believed to be the occlusion of the upper part of the folliculopilosebaceous unit, leading to the rupture of the sebofollicular canal with the consequent development of perifollicular lymphohistiocytic inflammation. The HS treatment choices are influenced by disease severity and its individual subjective impact, involving both medical and surgical interventions. However, given the chronic nature of HS, its destructive impact on social, working, and daily life of patients, its management is often frustrating for both the patient and physician. Hence, prompt and effective management strategies are urgently needed and a multidisciplinary approach is advocated. Therefore, in this article, we highlighted the main features of HS (clinical aspects, epidemiology, pathogenesis, diagnostic criteria, classifications, comorbidities, and treatments), so that awareness of this disease might be heightened in primary care physicians and surgeons, who may be the first health care providers to see patients with this disease owing to its characteristic clinical presentation (inflammatory nodules, abscesses, sinus tract, etc.).
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Affiliation(s)
- Nicolò Scuderi
- Department of Plastic, Reconstructive and Aesthetic Surgery, University of Rome "Sapienza," Rome, Naples, Italy
| | - Ambra Monfrecola
- Department of Plastic, Reconstructive and Aesthetic Surgery, University of Rome "Sapienza," Rome, Naples, Italy
| | - Luca Andrea Dessy
- Department of Plastic, Reconstructive and Aesthetic Surgery, University of Rome "Sapienza," Rome, Naples, Italy
| | - Gabriella Fabbrocini
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Matteo Megna
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Giuseppe Monfrecola
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
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Zouboulis CC, Desai N, Emtestam L, Hunger RE, Ioannides D, Juhász I, Lapins J, Matusiak L, Prens EP, Revuz J, Schneider-Burrus S, Szepietowski JC, van der Zee HH, Jemec GBE. European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa. J Eur Acad Dermatol Venereol 2015; 29:619-44. [PMID: 25640693 DOI: 10.1111/jdv.12966] [Citation(s) in RCA: 652] [Impact Index Per Article: 72.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 12/15/2014] [Indexed: 12/14/2022]
Abstract
Hidradenitis suppurativa/acne inversa (HS) is a chronic, inflammatory, recurrent, debilitating skin disease of the hair follicle that usually presents after puberty with painful, deep-seated, inflamed lesions in the apocrine gland-bearing areas of the body, most commonly the axillae, inguinal and anogenital regions. A mean disease incidence of 6.0 per 100,000 person-years and an average prevalence of 1% has been reported in Europe. HS has the highest impact on patients' quality of life among all assessed dermatological diseases. HS is associated with a variety of concomitant and secondary diseases, such as obesity, metabolic syndrome, inflammatory bowel disease, e.g. Crohn's disease, spondyloarthropathy, follicular occlusion syndrome and other hyperergic diseases. The central pathogenic event in HS is believed to be the occlusion of the upper part of the hair follicle leading to a perifollicular lympho-histiocytic inflammation. A highly significant association between the prevalence of HS and current smoking (Odds ratio 12.55) and overweight (Odds ratio 1.1 for each body mass index unit) has been documented. The European S1 HS guideline suggests that the disease should be treated based on its individual subjective impact and objective severity. Locally recurring lesions can be treated by classical surgery or LASER techniques, whereas medical treatment either as monotherapy or in combination with radical surgery is more appropriate for widely spread lesions. Medical therapy may include antibiotics (clindamycin plus rifampicine, tetracyclines), acitretin and biologics (adalimumab, infliximab). A Hurley severity grade-relevant treatment of HS is recommended by the expert group following a treatment algorithm. Adjuvant measurements, such as pain management, treatment of superinfections, weight loss and tobacco abstinence have to be considered.
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Affiliation(s)
- C C Zouboulis
- Departments of Dermatology, Venereology, Allergology and Immunology, Dessau Medical Center, Dessau, Germany
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Gill L, Williams M, Hamzavi I. Update on hidradenitis suppurativa: connecting the tracts. F1000PRIME REPORTS 2014; 6:112. [PMID: 25580266 PMCID: PMC4278191 DOI: 10.12703/p6-112] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Hidradenitis suppurativa (HS) is a debilitating skin disease characterized by recurrent abscesses, sinus tract formation, and scarring. Prevalence estimates range from 0.053% to 4.1%, although HS is likely an underdiagnosed disease. Although the first reports of HS date back to the mid-19th century, the disease continues to plague patients and physicians desperate for a definitive treatment. Advances in the understanding of the disease process include the possibility of a defective basement membrane at the sebofollicular junction of the folliculopilosebaceous unit (FPSU; that is, where the sebaceous gland empties into the hair follicle) as an initiating event followed by secondary bacterial colonization. New evidence suggests that bacteria living in a community, known as a biofilm, rather than single planktonic bacteria in HS lesions may explain why HS can be resistant to current antibiotic treatment regimens. Available treatment options have expanded to include triple-antibiotic therapy, tumor necrosis factor (TNF-α) and interleukin-1 (IL-1) inhibitors (biologics), laser therapy, and surgical excision, including the skin tissue-sparing excision with electrosurgical peeling procedure. Despite the array of treatments available, many patients continue to struggle with the embarrassment, pain, odor, and frustration that accompany this often isolating disease. Physicians should address comorbidities in HS, including the psychosocial issues patients with HS frequently encounter. Patients can be directed to HS support groups, where they can openly discuss their frustrations, share their experiences in dealing with HS, and band together to advocate for themselves. HS is misunderstood by both patients and physicians, often resulting in a delay in clinical presentation and diagnosis. Patients and physicians across multiple specialties must work together to expand awareness of and interest in HS, so that one day, individuals with HS can be freed from this crippling disease.
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Affiliation(s)
- Liza Gill
- College of Human Medicine, Michigan State University965 Fee Road, Room A110, East Lansing, MI 48824USA
| | - Melissa Williams
- Department of DermatologyHenry Ford Hospital, 3031 W. Grand Boulevard, Suite 800, Detroit, MI 48202USA
| | - Iltefat Hamzavi
- Department of DermatologyHenry Ford Hospital, 3031 W. Grand Boulevard, Suite 800, Detroit, MI 48202USA
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Samycia M, Brassard A. Adalimumab in treatment-resistant hidradenitis suppurativa following recurrence after extensive affected area excision: a review of biologics therapy. J Cutan Med Surg 2014; 17 Suppl 1:S23-32. [PMID: 24144253 DOI: 10.2310/7750.2012.11144] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hidradenitis suppurativa (HS) is characterized by chronic, suppurative abscesses, sinus tracts, and fistulas affecting the axilla, groin, and perianal region resulting from hyperkeratosis and occlusion of the terminal hair follicle. OBJECTIVE This report highlights the use of biologic agents for the treatment of recalcitrant HS. METHOD We report on a 48-year-old male with a 15-year history of refractory perianal-inguinal-buttock HS who, despite receiving numerous surgical drainages and traditional medical treatment for HS, still had severe pain. After trialing etanercept and infliximab with methotrexate, the patient had marked improvement with adalimumab. A literature review of biologics therapy was also performed. RESULTS After trialing many traditional therapies, we found that adalimumab appears to be the most effective treatment modality for our patient. A literature search revealed 53 articles on biologics therapy in HS. These articles are summarized. DISCUSSION Biologic agents have been shown to have variable results in the treatment of refractory HS. Enough low-grade evidence has been accumulated to make the use of these agents suitable in HS. Until more clinical trials are performed on this topic, physicians should use clinical judgment when treating HS with biologic agents and be cautious by watching for significant adverse effects.
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Bahillo Monné C, Honorato Guerra S, Schoendorff Ortega C, Gargallo Quintero AB. Management of Hidradenitis Suppurativa with Biological Therapy: Report of Four Cases and Review of the Literature. Dermatology 2014; 229:279-87. [DOI: 10.1159/000365076] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 06/04/2014] [Indexed: 11/19/2022] Open
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Nicoli F, Balzani A, Lazzeri D, Gentile P, Chilgar RM, Di Pasquali C, Nicoli M, Bocchini I, Agovino A, Cervelli V. Severe hidradenitis suppurativa treatment using platelet-rich plasma gel and Hyalomatrix. Int Wound J 2013; 12:338-43. [PMID: 23834343 DOI: 10.1111/iwj.12117] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 05/28/2013] [Accepted: 06/01/2013] [Indexed: 12/11/2022] Open
Abstract
Hidradenitis suppurativa (HS) can be a debilitating chronic disease. The underlying cause of the disease is still not clear. HS may be managed through numerous different medical or surgical procedures. Surgical treatment may consist of local excisions and reconstruction using a variety of methods: perforator flaps, skin grafts, local flaps, primary closure or secondary wound healing with vacuum and other devices. This report describes our experience with surgical excision and closure using platelet-rich plasma (PRP) gel and Hyalomatrix PA (HPA) in a patient with severe HS involving most of the body surface. We treated the patient with resection of severe HS of the nuchae and closure with PRP gel prepared with the RegenKit(®) to promote neovascularisation and HPA, a delivery system for hyaluronic acid, to induce a neodermis at the wound bed and to stimulate regeneration in a humid and protected environment. Complete wound healing was achieved after 2 months. The obtained result proved the efficacy of this treatment without complications. No recurrence was observed during the 1 year after the surgical procedure. Severe HS can be safely and effectively managed with wide excision, PRP gel and Hyalomatrix to achieve a successful outcome.
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Affiliation(s)
- Fabio Nicoli
- Department of Plastic and Reconstructive Surgery, 'Policlinico Casilino' University of Tor Vergata in Rome, Rome, Italy
| | - Alberto Balzani
- Department of Plastic and Reconstructive Surgery, 'Policlinico Casilino' University of Tor Vergata in Rome, Rome, Italy
| | - Davide Lazzeri
- Plastic and Reconstructive Surgery Unit, Hospital of Pisa, Pisa, Italy
| | - Pietro Gentile
- Department of Plastic and Reconstructive Surgery, 'Policlinico Casilino' University of Tor Vergata in Rome, Rome, Italy
| | - Ram M Chilgar
- Department of Plastic and Reconstructive Surgery, Maharashtra University of Health Sciences, Nashik, India
| | - Camilla Di Pasquali
- Department of Plastic and Reconstructive Surgery, 'Policlinico Casilino' University of Tor Vergata in Rome, Rome, Italy
| | - Marzia Nicoli
- Department of Immunology, 'La Sapienza' University, Rome, Italy
| | - Ilaria Bocchini
- Department of Plastic and Reconstructive Surgery, 'Policlinico Casilino' University of Tor Vergata in Rome, Rome, Italy
| | - Annarita Agovino
- Department of Plastic and Reconstructive Surgery, 'Policlinico Casilino' University of Tor Vergata in Rome, Rome, Italy
| | - Valerio Cervelli
- Department of Plastic and Reconstructive Surgery, 'Policlinico Casilino' University of Tor Vergata in Rome, Rome, Italy
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Blok J, van Hattem S, Jonkman M, Horváth B. Systemic therapy with immunosuppressive agents and retinoids in hidradenitis suppurativa: a systematic review. Br J Dermatol 2013; 168:243-52. [DOI: 10.1111/bjd.12104] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Revuz J. Les traitements antibiotiques dans l’hidradénite suppurée-maladie de Verneuil. Ann Dermatol Venereol 2012; 139:532-41. [DOI: 10.1016/j.annder.2012.05.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 04/17/2012] [Accepted: 05/02/2012] [Indexed: 11/16/2022]
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Paradela S, Rodríguez-Lojo R, Fernández-Torres R, Arévalo P, Fonseca E. Long-term efficacy of infliximab in hidradenitis suppurativa. J DERMATOL TREAT 2012; 23:278-83. [PMID: 22482700 DOI: 10.3109/09546634.2012.683767] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Hidradenitis suppurativa (HS) is a chronic disease with painful, inflamed lesions in the apocrine gland-bearing areas of the body and unsatisfactory treatment. TNFα blockers have been proposed as promising treatments, but only few randomized, short-term, small controlled trials have been conducted. The aim of this study was to evaluate long-term response of HS patients treated with infliximab (IFX). MATERIAL AND METHODS A long-term, prospective study of 10 patients with moderate-severe refractory HS treated with IFX was performed, including assessment of therapy safety, disease severity, and activity. Previous reports on IFX treatment for HS were reviewed. RESULTS Lack of response was observed in 20% and relapse in 50% of patients, after a median period of 37 weeks. The median number of doses administered was 7.5 during 49 weeks. No life-threatening adverse events were detected. Systematic review of 61 previously published cases showed lack of response was associated with previous surgery, young age at diagnosis, and long time of evolution of the disease. CONCLUSIONS Long-term IFX therapy might be an efficient, well-tolerated, safe option for patients with short-time evolution, severe HS. Relapse is common after 8 months of continuous treatment, especially in patients with more severe disease and in those treated with IFX in monotherapy.
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Affiliation(s)
- Sabela Paradela
- Department of Dermatology, University Hospital of La Coruña, La Coruña, Spain.
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van Rappard DC, Limpens J, Mekkes JR. The off-label treatment of severe hidradenitis suppurativa with TNF-α inhibitors: a systematic review. J DERMATOL TREAT 2012; 24:392-404. [PMID: 22397574 DOI: 10.3109/09546634.2012.674193] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
To provide an overview of the current evidence regarding off-label treatment of hidradenitis suppurativa (HS) with TNF-α inhibitors, a systematic search was performed in MEDLINE, EMBASE and CENTRAL. Any type of original article concerning HS patients treated with infliximab, etanercept and/or adalimumab was included. No language restriction was applied. After full-text screening 65 studies involving 459 patients met the inclusion criteria and were subjected to data extraction. Four randomized controlled trials (RCTs) were available, and the remainders were case series or reports. Only RTCs were subjected to methodological quality assessment. Based on efficacy data extracted from the case reports, a moderate to good response was seen in 82% of the patients treated with infliximab, 76% of the patients treated with adalimumab, and 68% of the patients treated with etanercept. Due to the moderate level of evidence only a weak recommendation can be provided. If conventional treatment options fail, the use of TNF-α inhibitors can be a useful supplement for the treatment of recurrent severe HS. Infliximab should be preferred based on the most encouraging results regarding efficacy and expenses. Also adalimumab seems promising when administered in higher doses. The use of etanercept should be discouraged.
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Affiliation(s)
- Dominique C van Rappard
- Department of Dermatology, Academic Medical Center, University of Amsterdam, The Netherlands.
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Chen E, Friedman HI. Management of regional hidradenitis suppurativa with vacuum-assisted closure and split thickness skin grafts. Ann Plast Surg 2012; 67:397-401. [PMID: 21587057 DOI: 10.1097/sap.0b013e3181f77bd6] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hidradenitis suppurativa can be a debilitating chronic illness. The underlying cause of the disease is still not clear, but effective treatment of widespread regional disease relies on resection of all the involved skin and subcutaneous tissue. Closure of the resulting large wound is dependent on either flap or skin graft coverage. Many of the resulting wounds are too large for flap closure or result in unacceptable flap donor site deficits. METHODS We present a series of 11 patients with 24 regional disease sites treated with a protocol of excision, followed by wound vacuum-assisted closure (VAC; KCI, San Antonio, TX) therapy to stimulate angiogenesis of exposed fat, and then skin grafting with the use of VAC to support the grafts on the recipient sites. RESULTS Only 3 of the patients required regrafting. One patient had a VAC failure because of poor patient compliance, and 1 patient had 4 sites that each required regrafting as the epithelium would not fill in the residual open areas as it usually did in other patients. All patients were cured of their local disease. CONCLUSIONS Massive regional hidradenitis suppurativa can be successfully managed with wide excision, VAC therapy, and skin grafting to allow these patients to live normal and productive lives.
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Affiliation(s)
- Elliott Chen
- Division of Plastic Surgery, Department of Surgery, University of South Carolina School of Medicine, Columbia, SC 29203, USA
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Dessinioti C, Stratigos AJ, Katsambas A, Antoniou C. Anti-tumor necrosis factor-α therapies for immune-mediated and inflammatory skin diseases. Drug Dev Res 2011. [DOI: 10.1002/ddr.20471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Arenbergerova M, Gkalpakiotis S, Arenberger P. Effective long-term control of refractory hidradenitis suppurativa with adalimumab after failure of conventional therapy. Int J Dermatol 2011; 49:1445-9. [PMID: 21091684 DOI: 10.1111/j.1365-4632.2010.04638.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hidradenitis suppurativa is a chronic suppurative condition featuring inflammatory nodules, fistulas and scars. It occurs predominantly in the axillae and groin. The disease is poorly responsive to any treatment and is connected with significant morbidity. Systemic therapy, including oral antibiotics, retinoids and antiandrogens, usually has only limited effect. Surgical treatment of affected areas is necessary in advanced stages. OBJECTIVES Several reports support the beneficial effect of tumor necrosis factor-α (TNF-α) antagonists for the treatment of severe hidradenitis suppurativa. By contrast with data on infliximab and etanercept, data describing the potential positive influence of adalimumab on disease outcome are limited and refer to only small cohorts of patients. METHODS Eight patients with severe, recalcitrant hidradenitis were treated for 1 year with adalimumab in a standard regimen and were subsequently followed for 1 year. RESULTS All patients improved within 4-6 weeks and laboratory parameters of C-reactive protein (CRP) and leukocyte count reduced significantly during treatment. Three patients demonstrated long-lasting improvement and five showed recurrences several months after discontinuation of the therapy. The average recurrence-free interval was 9.5 months. CONCLUSIONS Adalimumab is suitable for the long-term treatment of hidradenitis suppurativa and presents a further conservative treatment approach.
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Affiliation(s)
- Monika Arenbergerova
- Department of Dermatovenereology, Third Faculty of Medicine, Charles University, Prague, Czech Republic.
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Abstract
Hidradenitis suppurativa (HS) is a chronic, inflammatory, scarring condition involving the intertriginous skin of the axillary, inguinal, inframammary, genital, and perineal areas of the body. It is also referred to as acne inversa and Verneuil disease. Follicular occlusion is the primary event in HS. It is now accepted that the first pathogenetic change is in the pilosebaceous follicular ducts, like acne, and so there has been a move to rename this disorder acne inversa. Despite the legitimate argument that hidradenitis suppurativa is a misnomer, the term has become generally accepted.
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Revuz J. Hidradenitis suppurativa. Presse Med 2010; 39:1254-64. [DOI: 10.1016/j.lpm.2010.08.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Revised: 08/23/2010] [Accepted: 08/31/2010] [Indexed: 11/30/2022] Open
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Deschamps ME, Payet S, Tournadre A, Soubrier M, Souteyrand P, D’Incan M. Efficacité de l’infliximab dans le traitement d’une triade d’occlusion folliculaire. Ann Dermatol Venereol 2010; 137:546-50. [DOI: 10.1016/j.annder.2010.06.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2009] [Accepted: 04/30/2010] [Indexed: 11/28/2022]
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Biologic Drugs for the Treatment of Hidradenitis Suppurativa: An Evidence-Based Review. Dermatol Clin 2010; 28:511-21, 523-4; quiz 522-3. [DOI: 10.1016/j.det.2010.03.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Treatment of acne conglobata with modern external beam radiation. J Am Acad Dermatol 2010; 62:861-3. [DOI: 10.1016/j.jaad.2009.06.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2008] [Revised: 03/01/2009] [Accepted: 06/08/2009] [Indexed: 11/20/2022]
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Mahmoud BH, Tierney E, Hexsel CL, Pui J, Ozog DM, Hamzavi IH. Prospective controlled clinical and histopathologic study of hidradenitis suppurativa treated with the long-pulsed neodymium:yttrium-aluminium-garnet laser. J Am Acad Dermatol 2010; 62:637-45. [PMID: 20227579 DOI: 10.1016/j.jaad.2009.07.048] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2008] [Revised: 07/08/2009] [Accepted: 07/08/2009] [Indexed: 10/19/2022]
Abstract
BACKGROUND Hidradenitis suppurativa (HS) is a chronic inflammatory disease involving the intertriginous areas. OBJECTIVE We sought to conduct clinical and histopathologic evaluation of the efficacy of long-pulsed neodymium:yttrium-aluminium-garnet laser treatment for HS. METHODS We conducted a prospective, randomized, right-left within-patient controlled trial for HS (n = 22). Four monthly laser sessions were performed. Disease activity was measured at baseline, and treatment response was assessed before each laser session and monthly for 2 months after the completion of laser treatment, using a modified scoring system based on Sartorius score. Histologic examination was performed at baseline, immediately after laser treatment, and at 1 and 4 weeks after treatment. A patient questionnaire was circulated on the last visit to assess patients' level of satisfaction. RESULTS There was progressive improvement in disease activity, most significantly during the 4 months of treatment, which was maintained during the 2-month posttreatment follow-up period. Averaged over all anatomic sites, the percent improvement was 72.7% on the laser treated side, and 22.9% on the control side (P < .05). Histologic examination showed an initial acute neutrophilic infiltrate. Granulomatous inflammation was present on follow-up biopsy specimens 4 weeks later. An inflammatory infiltrate surrounded the hair shaft remnants, denoting destruction of hair follicles. LIMITATIONS Small sample size was a limitation. CONCLUSIONS Long-pulsed neodymium:yttrium-aluminium-garnet laser, together with topical benzoyl peroxide and clindamycin, is significantly more effective than topical benzoyl peroxide and clindamycin alone for the treatment of HS. Preliminary review of histopathology suggests the mechanism of action is destruction of the hair follicle. The overall success of the treatment in both clearing pre-existing lesions and preventing new eruptions, coupled with high patient satisfaction, makes the neodymium:yttrium-aluminium-garnet laser a promising treatment advance for this highly disabling condition.
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Affiliation(s)
- Bassel H Mahmoud
- Mulitcultural Dermatology Center, Department of Dermatology, Henry Ford Hospital, Detroit, Michigan, USA
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Abstract
Acne inversa is a chronic inflammatory disease of the hair follicles. It can lead to severe functional and psychological impairment. It is characterized by inflamed painful nodules, abscesses, fistulas and scarring in late stages of the disease. The causes of acne inversa are still not fully understood. Conservative treatment options such as antibiotics may lead to clinical improvement; however they do not produce healing. Therapy of choice, especially in severe forms, is radical wide excision of all affected areas. Despite a variety of treatment options, acne inversa is still a therapeutic challenge.
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Affiliation(s)
- F G Bechara
- Klinik für Dermatologie und Allergologie, Ruhr-Universität Bochum, Bochum, Deutschland.
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Sartorius K, Killasli H, Heilborn J, Jemec G, Lapins J, Emtestam L. Interobserver variability of clinical scores in hidradenitis suppurativa is low. Br J Dermatol 2010; 162:1261-8. [DOI: 10.1111/j.1365-2133.2010.09715.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Hidradenitis suppurativa is a chronic disease characterized by recurrent, painful, deep-seated, rounded nodules and abscesses of apocrine gland-bearing skin. Subsequent suppuration, sinus tracts and hypertrophic scarring are its main features. Onset is usually after puberty, although it is most common during the third decade and may persist in old age. The disease tends to be chronic and may develop to subcutaneous extension leading to indurations, sinus, and fistula having a profound impact on the quality of life. The prevalence is 1% in several studies. Axillary and inguinal involvement is more common in females; peri-anal and buttocks localizations are prevalent in males. The exact aetiology remains unknown. The primary event is a follicular occlusion with secondary inflammation, infection and destruction of the pilo-sebaceo-apocrine apparatus and extension to the adjacent sub-cutaneous tissue. Infection is common. Smoking may be a triggering factor. Obesity aggravates the discomfort. Differential diagnostic includes Crohn's disease, nodular acne and furonculosis. The main complications are arthropathy, carcinoma. Treatment depends upon the stage of the disease. Early nodular lesions may be treated by antibiotics for acute stage; long-term antibiotics, zinc salts may be useful as maintenance treatment; anti-TNF drugs have been used in severe cases; systemic steroids, estrogens, anti-androgens, retinoids have been used as options with limited success. Surgical treatment includes incision with or without drainage for limited abscesses; limited excisions are used for locally recurring draining sinuses. Total wide excision and healing with secondary intention or flaps and grafts is the only curative procedure in case of advanced disease.
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Pelekanou A, Kanni T, Savva A, Mouktaroudi M, Raftogiannis M, Kotsaki A, Giamarellos-Bourboulis EJ. Long-term efficacy of etanercept in hidradenitis suppurativa: results from an open-label phase II prospective trial. Exp Dermatol 2009; 19:538-40. [PMID: 19758320 DOI: 10.1111/j.1600-0625.2009.00967.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the long-term efficacy of etanercept for the management of hidradenitis suppurativa. METHODS Analysis was based on the long-term follow-up (weeks 24-144) of 10 patients enrolled in a prospective open-label phase II study; etanercept was initially administered subcutaneously 50 mg once weekly for 12 weeks in 10 patients. Disease recurrence and the need to restart etanercept were recorded. RESULTS Three patients did not report any disease recurrence. A second course of treatment with etanercept was needed in seven patients. Favourable responses were found in five; two patients failed treatment. CONCLUSIONS The first treatment course achieved long-term disease remission in almost one-third of patients. The remaining needed a second treatment course but even in that case, their disease severity at restart was significantly lower compared with baseline.
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Alexandroff A, Burd R. Footprints of the EADV: a meeting report from the 17th Congress of the European Academy of Dermatology and Venereology. Br J Dermatol 2009; 160:938-45. [DOI: 10.1111/j.1365-2133.2009.09107.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Sartorius K, Emtestam L, Jemec GBE, Lapins J. Objective scoring of hidradenitis suppurativa reflecting the role of tobacco smoking and obesity. Br J Dermatol 2009; 161:831-9. [PMID: 19438453 DOI: 10.1111/j.1365-2133.2009.09198.x] [Citation(s) in RCA: 341] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hidradenitis suppurativa (HS) is a long-standing disease with abscess and often fistula formation, predominantly in the axillae and groins. The disease is difficult to treat and has a severe impact on quality of life. A clinically relevant system for scoring disease severity is lacking in HS. OBJECTIVES To evaluate the modified Hidradenitis Suppurativa Score (HSS) and to study the impact of body mass index (BMI) and smoking habits on disease severity. METHODS Two hundred and fifty-one consecutive patients with HS referred to a clinic with special interest in the disease were included, of whom 115 were scored. Points were given for regions involved, types of lesion (nodules, fistulas), total area involved and whether lesions were separated by normal skin. Background characteristics included BMI and smoking habits. Two hundred and forty-six patients completed the Dermatology Life Quality Index (DLQI). RESULTS The median (interquartile range, IQR) HSS for all patients was 38 (18-66): women 38 (18-71) and men 37 (19-51). Median (IQR) HSS for smokers was 41 (22-75.5), former smokers 27 (16-53) and nonsmokers 22 (10-57). Median (IQR) HSS for patients with BMI < 25 kg m(-2) was 32 (12-54), BMI 25-30 kg m(-2) 44 (22-56) and BMI > or = 30 kg m(-2) 50 (18-86). Mean +/- SD DLQI for the whole group of patients was 10.3 +/- 7.5, median 9, and showed no significant differences between the groups studied. There was a significant positive correlation of fair degree between HSS and DLQI. There were significant differences in HSS between nonsmokers and smokers as well as between women of normal weight compared with obese women. CONCLUSIONS The modified HSS is simple and practical and it extracts important clinical information. A connection between disease severity and BMI as well as smoking habits in patients with HS is presented. The results suggest that the HSS may be a relevant outcome measure in future therapeutic trials in HS.
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Affiliation(s)
- K Sartorius
- Section of Dermatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden.
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Alikhan A, Lynch PJ, Eisen DB. Hidradenitis suppurativa: a comprehensive review. J Am Acad Dermatol 2009; 60:539-61; quiz 562-3. [PMID: 19293006 DOI: 10.1016/j.jaad.2008.11.911] [Citation(s) in RCA: 395] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Revised: 10/10/2008] [Accepted: 11/17/2008] [Indexed: 12/14/2022]
Abstract
Hidradenitis suppurativa, also known as acne inversa, is a chronic, often debilitating disease primarily affecting the axillae, perineum, and inframammary regions. Prevalence rates of up to 4% have been estimated. Our understanding of the disease has changed over time. It is now considered a disease of follicular occlusion rather than an inflammatory or infectious process of the apocrine glands. Clinically, the disease often presents with tender subcutaneous nodules beginning around puberty. The nodules may spontaneously rupture or coalesce, forming painful, deep dermal abscesses. Eventually, fibrosis and the formation of extensive sinus tracts may result. The location of the lesions may lead to social embarrassment and the failure to seek medical treatment. Therapies in the past have consisted of long-term antibiotics, antiandrogens, and surgery. New treatments like tumor necrosis factor-alfa inhibitors have given clinicians more options against this difficult disease.
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Affiliation(s)
- Ali Alikhan
- University of California-Davis School of Medicine, Sacramento, California 95816, USA
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