Section 2: Acneiform Disorders

Patient Story

A 16-year-old boy (Figure 96-1) with severe nodulocystic acne and scarring presents for treatment. After trying oral antibiotics, topical retinoids, and topical benzyl peroxide with no significant benefit, the patient and his mother request isotretinoin (Accutane). After 4 months of isotretinoin, the nodules and cysts cleared, and there remained only a few papules (Figure 96-2). He is much happier and more confident about his appearance. The skin fully cleared after the last month of isotretinoin.

Introduction

Acne is an obstructive and inflammatory disease of the pilosebaceous unit predominantly found on the face of adolescents. However, it can occur at any age and often involves the trunk in addition to the face.

Epidemiology

Acne vulgaris affects more than 80 percent of teenagers, and persists beyond the age of 25 years in 3 percent of men and 12 percent of women.¹

Etiology and Pathophysiology

The four most important steps in acne pathogenesis:

1. Sebum overproduction related to androgenic hormones and genetics.

2. Abnormal desquamation of the follicular epithelium (keratin plugging).

3. Propionibacterium acnes proliferation.

4. Follicular obstruction, which can lead to inflammation and follicular disruption.

Neonatal acne is thought to be related to maternal hormones and is temporary (Figure 96-3).

Acne can be precipitated by mechanical pressure as with a helmet strap (Figure 96-4) and medications such as phenytoin and lithium (Figure 96-5).

There are some studies that suggest that consumption of large quantities of milk (especially skim milk) increase the risk for acne in teenagers.²

Diagnosis

Clinical Features

Morphology of acne includes comedones, papules, pustules, nodules, and cysts.

• Obstructive acne = comedonal acne = noninflammatory acne and consists of only comedones (Figure 96-6).

• Open comedones are blackheads (Figure 96-7) and closed comedones are called whiteheads and look like small papules.

• Inflammatory acne has papules, pustules, nodules, and cysts in addition to comedones (Figure 96-5).

Typical Distribution

Face, back, chest, and neck.

Laboratory Studies

None unless you suspect androgen excess and/or polycystic ovarian syndrome (PCOS).³ SOR A Obtain testosterone and DHEA-S levels if you suspect androgen excess and/or PCOS.

Consider follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels if you suspect PCOS.

Differential Diagnosis (Including Special Types of Acne)

• Acne conglobata is an uncommon and unusually severe form of acne characterized by multiple comedones, cysts, sinus tracks, and abscesses. The inflammatory lesions and scars can lead to significant disfigurement.⁴ Sinus tracks can form with multiple openings that drain foul-smelling purulent material (Figures 96-8 and 96-9). The comedones and nodules are usually found on the chest, shoulders, back, buttocks, and face. In some cases, acne conglobata is part of a follicular occlusion triad including hidradenitis and dissecting cellulitis of the scalp.

• Acne fulminans is characterized by sudden onset ulcerative crusting cystic acne, mostly on the chest and back (Figures 96-10 and 96-11).⁵ Fever, malaise, nausea, arthralgia, myalgia, and weight loss are common. Leukocytosis and elevated erythrocyte sedimentation rate are usually found. There may also be focal osteolytic lesions. The term acne fulminans may also be used in cases of severe aggravation of acne without systemic features.⁵

• Pomade acne is described as acne that is caused or exacerbate by greasy hair products that get on the skin of the forehead. It is more commonly seen in African Americans (Figure 96-12).

• Rosacea can resemble acne by having papules and pustules on the face. It is usually seen in older adults with prominent erythema and telangiectasias. Rosacea does not include comedones and may have ocular or nasal manifestations (Chapter 97, Rosacea).

• Folliculitis on the back may be confused with acne. Look for hairs centrally located in the inflammatory papules of folliculitis to help distinguish it from acne. Acne on the back usually accompanies acne on the face as well (Chapter 100, Folliculitis).

• Acne keloidalis nuchae consists of papules, pustules, nodules, and keloidal tissue found at the posterior hairline. It is most often seen in persons of color after shaving the hair at the nape of the neck (Figure 96-13).

Management

Treatment is based on type of acne and severity. Categories to choose from are topical retinoids, topical antimicrobials, systemic antimicrobials, hormonal therapy, oral isotretinoin, and injection therapy.

Medications For Acne Therapy

In a review of 250 comparisons, the Agency for Health-care Research and Quality found 14 had evidence of level A.⁶ These comparisons demonstrated the efficacy over vehicle or placebo control of topical clindamycin, topical erythromycin, benzoyl peroxide, topical tretinoin, oral tetracycline, and norgestimate/ethinyl estradiol.⁴ Level A conclusions demonstrating equivalence include: Benzoyl peroxide at various strengths was equally efficacious in mild/moderate acne; adapalene and tretinoin were equally efficacious.⁶ SOR A

Topical:

• Benzoyl peroxide—Antimicrobial effect (gel, cream, lotion) (2.5%, 5%, 10%) 10 percent causes more irritation and is not more effective.¹ SOR A

• Topical antibiotics—Clindamycin and erythromycin are the mainstays of treatment.

• Erythromycin—Solution, gel.³ SOR A

• Clindamycin—Solution, gel, lotion.³ SOR A

• Benzamycin gel—Erythromycin 3 percent, benzoyl peroxide 5 percent.³ SOR A

• BenzaClin gel—Clindamycin 1 percent, benzoyl peroxide 5 percent.³ SOR A

• Dapsone 5 percent gel.⁷ SOR B

Retinoids:

• Tretinoin (Retin-A) gel, cream, liquid, micronized.¹ SOR A

• Adapalene gel—Less irritating than tretinoin.¹ SOR A

• Tazarotene—Strongest topical retinoid with greatest risk of irritation.⁸ SOR A

Topical retinoids will often result in skin irritation during the first 2 to 3 months of treatment, but new systematic reviews do not demonstrate that they worsen acne lesion counts during the initial period of use.²

• Azelaic acid—Useful to treat spotty hyperpigmentation and acne (Figure 96-14).³ SOR B

Systemic

• Oral antibiotics.

  • Doxycycline 40 to 100 mg qd to bid—Inexpensive, well tolerated, can take with food and increases sun sensitivity.³ SOR A

  • Minocycline 50 to 100 mg qd to bid—Expensive, not proven to be better than other systemic antibiotics including tetracycline.^3,9 SOR A

  • Erythromycin 250 to 500 mg bid—Inexpensive, frequent gastrointestinal (GI) disturbance but can be used in pregnancy.³ SOR A

  • Trimethoprim/sulfamethoxazole DS bid—Effective but risk of Stevens-Johnson syndrome is real. Reserve for short courses in particularly severe and resistant cases.³ SOR A

  • Oral azithromycin has been prescribed in pulse dosing for acne in a number of small poorly done studies and has not been found to be better than oral doxycyline.¹⁰

• Isotretinoin (Accutane) is the most powerful treatment for acne. It is especially useful for cystic and scarring acne that has not responded to other therapies.³ SOR A Dosed at approximately 1 mg/kg per day for 5 months. Any female of childbearing potential must be abstinent from sexual intercourse or use two forms of contraception. Other risks that are controversial but important to discuss with patients and their parents are depression, suicide, and inflammatory bowel disease.

• The US Food and Drug Administration requires that prescribers of isotretinoin, patients who take isotretinoin, and pharmacists who dispense isotretinoin all must register with the iPLEDGE system (www.ipledgeprogram.com).

• Hormonal treatments are for females only:

  • Oral contraceptives—Choose ones with low androgenic effect.³ SOR A FDA-approved oral contraceptives are Ortho Tri-Cyclen, Yaz, and Estrostep. Other oral contraceptives with similar formulations also help acne in women even though these have not received FDA approval for this indication. Note: Yaz and Yasmin have progestin drospirenone, which is derived from 17a-spirolactone. It shares an antiandrogenic effect with spironolactone.

Complementary/Alternative Therapy

Tea tree oil 5 percent gel.¹¹ SOR B

Acne Procedures

• Steroid injections for acne are useful for painful nodules and cysts. SOR C Patients often report that the lesion flattens and becomes painless by the next day. Follow these directions to avoid producing skin atrophy.

  • Dilute 0.1 mL of 10 mg/mL triamcinolone acetonide (Kenalog) with 0.4 mL of sterile saline in a 0.1 mL syringe to make a 2 mg/mL suspension. Shake the suspension well before injecting.

  • Inject 0.1 mL of this suspension into each nodule or cyst using a 30-gauge needle (Figure 96-15).

• Acne surgery is a fancy name for extracting the material from open comedones. It helps to nick the comedone with a needle or #11 blade before expressing the material with a comedone extractor (Figure 96-16). The patient in Figure 96-7 is a very good candidate for this procedure along with medical therapy.

Acne Therapy By Severity

Comedonal acne (Figures 96-6, 96-7, 96-17)

• Topical retinoids or azelaic acid are the most beneficial agents.

• No need for antibiotics—Do not need to kill P. acnes.

• Benzoyl peroxide may be beneficial.

Mild papulopustular

• Topical antibiotics and benzoyl peroxide.

• Topical retinoid or azelaic acid.

• May add oral antibiotics if topical agents are not working (Figure 96-18).

Papulopustular or nodulocystic acne—moderate to severe—inflammatory

• Topical antibiotic, benzoyl peroxide, and oral antibiotic.

• Oral antibiotics are often essential at this stage especially if the trunk is involved.

• Topical retinoid or azelaic acid.

• Steroid injection therapy—For painful nodules and cysts.

Severe cystic or scarring acne

• Isotretinoin if there are no contraindications (Figure 96-19).

• Steroid injection therapy—For painful nodules and cysts.

Acne fulminans (Figures 96-10 and 96-11)

• Start with systemic steroids (prednisone 40 to 60 mg/day—Approximately 1 mg/kg per day).¹² SOR C

• Systemic steroid treatment rapidly controls the skin lesions and systemic symptoms. The duration of steroid treatment in one Finnish series was 2 to 4 months to avoid relapses.¹² SOR C

• Therapy with isotretinoin, antibiotics, or both was often combined with steroids, but the role of these agents is still uncertain.¹² SOR C

• One British series used oral prednisolone 0.5 to 1 mg/kg daily for 4 to 6 weeks (thereafter slowly reduced to zero).¹³ SOR C

• Oral isotretinoin was added to the regimen at the fourth week, initially at 0.5 mg/kg daily and gradually increased to achieve complete clearance.¹³ SOR C

• Consider introducing isotretinoin at approximately 4 weeks into the oral prednisone if there are no contraindications. SOR C

Acne conglobata (Figures 96-8 and 96-9) may be treated like acne fulminans but the course of oral prednisone does not need to be as long. SOR C

Combination Therapies

• Combination therapy with multiple topical agents can be more effective than single agents.³ SOR B

• Topical retinoids and topical antibiotics are more effective when used in combination than when either are used alone.³ SOR B

• Benzoyl peroxide and topical antibiotics used in combination are effective treatment for acne by helping to minimize antibiotic resistance.³ SOR B

• The adjunctive use of clindamycin/benzoyl peroxide gel with tazarotene cream promotes greater efficacy and may also enhance tolerability.¹⁴

• Combination therapy with topical retinoids and oral antibiotics can be helpful at the start of acne therapy. However, maintenance therapy with combination tazarotene and minocycline therapy showed a trend for greater efficacy but no statistical significance versus tazarotene alone.¹⁵

Medication Cost

The most affordable medications for acne include topical benzoyl peroxide, erythromycin, clindamycin, and oral tetracycline and doxycycline. The most expensive acne medications are the newest brand-name combination products of existing topical medication. These medications are convenient for those with insurance that covers them (Epiduo contains benzoyl peroxide and adapalene; Ziana contains clindamycin and tretinoin).

Newer Expensive Modes of Therapy

Intense pulsed light and photodynamic therapy (PDT) use lasers, special lights, and topical chemicals to treat acne.^16–18 These therapies are very expensive and the data do not suggest that these should be first-line therapies at this time. Light and laser treatments have been shown to be of short-term benefit if patients can afford therapy and tolerate some discomfort. These therapies have not been shown to be better than simple topical treatments.²

One comparative trial demonstrated that PDT was less effective than topical adapalene in the short-term reduction of inflammatory lesions.²

Follow-Up

Isotretinoin requires monthly follow-up visits but other therapies can be monitored every few months at first and then once to twice a year. Keep in mind that many treatments for acne take months to work, so quick follow-up visits may be disappointing.

Patient Education

Adherence with medication regimens is crucial to the success of the therapy. Adequate face washing twice a day is sufficient. Do not scrub the face with abrasive physical or chemical agents. If benzoyl peroxide is not being used as a leave-on product, it can be purchased to use for face washing.

Patient Story

A 14-year-old girl presents with a red face and a history of easy facial flushing over the last two years (Figure 97-1). Her face has become persistently redder and she would like some treatment.

Her mom is in the room and has similar redness in her face. The family is from northern European heritage. The girl also has developed some “pimples.” Physical examination reveals some papules and erythema. No comedones are seen. She knows that the sun makes it worse but finds that many sunscreens are irritating to her skin. The patient is started on 0.75 percent metronidazole gel once daily. She agrees to wear a hat and stay out of the sun during the middle of the day. She will continue to look for a sunscreen she can tolerate. She knows that precipitating factors for her include hot and humid weather, alcohol, hot beverages, and spicy foods.

Introduction

Rosacea is an inflammatory condition of the face and eyes that mostly affects adults but can start in childhood. Most commonly the face becomes reddened over the cheeks and nose and this is often accompanied by telangiectasias and a papulopustular eruption (Figures 97-2 and 97-3).

Synonyms

Rosacea is also called acne rosacea.

Epidemiology

• Common in fair-skinned people of Celtic and northern European heritage.

• Women and girls are more often affected than men and boys.

• Men are more prone to the extreme forms of hyperplasia, which causes rhinophymatous rosacea. However, even young women can have rhinophymatous rosacea. (Figure 97-4).

Etiology and Pathophysiology

• Although the exact etiology is unknown, the pathophysiology involves nonspecific inflammation followed by dilation around follicles and hyperreactive capillaries. These dilated capillaries become telangiectasias (Figures 97-5).

• As rosacea progresses, diffuse hypertrophy of the connective tissue and sebaceous glands ensues (Figure 97-4).

• Alcohol may accentuate erythema, but does not cause the disease. Rosacea runs in families.

• Sun exposure may precipitate an acute rosacea flare, but flare-ups can happen without sun exposure.

• A significant increase in the hair follicle mite Demodex folliculorum is sometimes found in rosacea.¹ It is theorized that these mites play a role because they incite an inflammatory or allergic reaction by mechanical blockage of follicles.

Risk Factors

Genetics, Demodex infestation,¹ sun exposure.

Diagnosis

Clinical Features

Rosacea has four stages or subtypes:

1. Erythematotelangiectatic rosacea (Figure 97-5)—This stage is characterized by frequent mild to severe flushing with persistent central facial erythema.

2. Papulopustular rosacea (Figure 97-6)—This is a highly vascular stage that involves longer periods of flushing than the first stage, often lasting from days to weeks. Minute telangiectasias and papules start to form by this stage, and some patients begin having very mild ocular complaints such as ocular grittiness or conjunctivitis. These patients may have many unsightly pustules with severe facial erythema. They are more prone to develop a hordeolum (stye) (see Chapter 10, Hordeolum and Chalazion).

3. Phymatous or Rhinophymatous rosacea (Figure 97-4)—Characterized by hyperplasia of the sebaceous glands that form thickened confluent plaques on the nose known as rhinophyma. This hyperplasia can cause significant disfigurement to the forehead, eyelids, chin, and nose. The nasal disfiguration is seen more commonly in men than women. W. C. Fields is famous for his rhinophyma and intake of alcohol. Rhinophyma can occur without any alcohol use.

4. Ocular rosacea (Figures 97-7 and 97-8)—An advanced subtype of rosacea that is characterized by impressive, severe flushing with persistent telangiectasias, papules, and pustules. The patient may complain of watery eyes, a foreign-body sensation, burning, dryness, vision changes, and lid or periocular erythema. The eyelids are most commonly involved with telangiectasias, blepharitis, and recurrent hordeola and chalazia (Figure 97-7). Conjunctivitis may be chronic. Although corneal involvement is least common, it can have the most devastating consequences. Corneal findings may include punctate erosions, corneal infiltrates, and corneal neovascularization. In the most severe cases, blood vessels may grow over the cornea and lead to blindness (Figure 97-8).

Typical Distribution

Rosacea occurs on the face, especially on the cheeks and nose. However, the forehead, eyelids, and chin can also be involved.

Laboratory Studies

Not needed when the clinical picture is clear. If you are considering lupus or sarcoid, an antinuclear antibody (ANA), chest x-ray, or punch biopsy may be needed (Figure 97-9).

Differential Diagnosis

• Acne—The age of onset for rosacea tends to be 30 to 50 years, much later than the onset for acne vulgaris. Comedones are prominent in most cases of acne and generally absent in rosacea (see Chapter 96, Acne Vulgaris).

• Sarcoidosis on the face is much less common than rosacea, but the inflamed plaques can be red and resemble the inflammation of rosacea (see Chapter 150, Sarcoidosis).

• Seborrheic dermatitis tends to produce scale, whereas rosacea does not. Although both cause central facial erythema, papules and telangiectasias are present in rosacea and are not part of seborrheic dermatitis (see Chapter 135, Seborrheic Dermatitis).

• Systemic lupus erythematosus (SLE) can be scarring, does not usually produce papules or pustules, and it spares the nasolabial folds and nose (see Chapter 173, Lupus: Systemic and Cutaneous). The patient in Figure 97-9 has a butterfly distribution of her rosacea, but her biopsy clearly demonstrated the histology of rosacea.

The following three diagnoses were once considered variants of rosacea but a recent classification system identified these as separate entities:²

• Rosacea fulminans (known as pyoderma faciale) is characterized by the sudden appearance of papules, pustules, and nodules, along with fluctuating and draining sinuses that may be interconnecting. The condition appears primarily in women in their 20s, and intense redness and edema also may be prominent.²

• Steroid-induced acneiform eruption is not a variant of rosacea and can occur as an inflammatory response in any patient during or after chronic corticosteroid use. The same inflammatory response may also occur in patients with rosacea.

• Perioral dermatitis without rosacea symptoms should not be classified as a variant of rosacea. Perioral dermatitis is characterized by microvesicles, scaling, and peeling around the mouth (Figure 97-10). Perioraficial dermatitis is the same condition but may involve the skin around the nares and eyes (Figure 97-11).

Management

• A Cochrane Database systematic review examined the efficacy of rosacea interventions.³ Oral doxycycline appeared to be significantly more effective than placebo and there was no statistically significant difference in effectiveness between the 100-mg and 40-mg doses.³ SOR A They found some evidence to support the effectiveness of topical metronidazole (0.75% or 1%), azelaic acid (15% or 20%) for the treatment of moderate to severe rosacea.³ SOR A Cyclosporine ophthalmic emulsion was significantly more effective than artificial tears for treating ocular rosacea (for all outcomes).³ SOR A

• When there are a limited number of papules and pustules, start with topical metronidazole (0.75% or 1%) or topical azelaic acid (15% or 20%).³

  • There are no substantial differences between topical metronidazole of 0.75 percent and 1 percent, or between once daily and twice daily regimens.⁴ Metronidazole cream, gel, and lotion have similar efficacies as well.⁴

• Azelaic acid in a 15 percent gel applied bid appeared to offer some modest benefits over 0.75 percent metronidazole gel in a manufacturer-sponsored study.⁴ Azelaic acid was not as well tolerated, so both medications are reasonable options with the choice depending on patient preference and tolerance.³ SOR B One study found that once-daily azelaic acid 15 percent gel was as effective as twice-daily application, which can translate into a significant cost saving.⁵

• If the skin lesions are more extensive, oral antibiotics, such as doxycycline (40 mg or 100 mg daily) is recommended.³ SOR A When attempting to avoid the photosensitivity side effects of doxycycline it is reasonable to prescribe oral tetracycline (250 mg to 500 mg daily) or oral metronidazole (250 mg to 500 mg daily). SOR C

• Patients who are started on oral antibiotics alone and improve may be switched to topical agents such as metronidazole or azelaic acid for maintenance.

• The Demodex mite may be one causative agent in rosacea. One study found permethrin 5 percent cream to be as effective as metronidazole 0.75 percent gel and superior to placebo in the treatment of rosacea.⁵ SOR B

• Severe papulopustular disease refractory to antibiotics and topical treatments can be treated with oral isotretinoin at a low dose of 0.3 mg/kg per day.⁶ SOR B

• Simple electrosurgery or laser without anesthesia can be used to treat the telangiectasias associated with rosacea. SOR C

• Rhinophyma can be excised with radiofrequency electrosurgery or laser. Isotretinoin is also used to treat rhinophyma.⁶ SOR B

• Traditional therapies for mild ocular rosacea include oral tetracyclines, lid hygiene, and warm compresses.¹ SOR C Topical ophthalmic cyclosporine 0.05 percent (Restasis) is more effective than artificial tears for the treatment of rosacea-associated lid and corneal changes.⁷ SOR B Ocular rosacea that involves the cornea should be immediately referred to an ophthalmologist to prevent blindness (Figure 97-8).

Follow-Up

Follow-up can be in 1 to 3 months as needed.

Patient Education

Sun protection, including use of a hat and daily application of sunscreen, should be emphasized. Choose a sunscreen that is nonirritating and protects against UVA and UVB rays. Advise patients to keep a diary to identify and avoid precipitating factors such as hot and humid weather, alcohol, hot beverages, spicy foods, and large hot meals.

Patient Story

A 17-year-old teenager presents with new tender lesions in her axilla that started during her period 2 weeks ago (Figure 98-1). She has had two similar outbreaks in the axilla the year before. The clinician determined that the diagnosis was a mild case of hidradenitis suppurativa with folliculitis as an alternative diagnosis to be considered. The patient was started on doxycycline 100 mg twice daily and the condition cleared within 1 month. The patient was also a one pack per day smoker and she agreed to quit smoking for her health and to decrease her risk of further outbreaks of hidradenitis.

Introduction

Hidradenitis suppurativa (HS) is an inflammatory disease of the pilosebaceous unit in the apocrine gland-bearing skin. HS is most common in the axilla and inguinal area, but may be found in the inframammary area as well. It produces painful inflammatory nodules, cysts, and sinus tracks with mucopurulent discharge and progressive scarring.

Synonyms

It is called acne inversa because it involves intertriginous areas and not the regions affected by acne (similar to inverse psoriasis).

Epidemiology

• Occurs after puberty in approximately 1 percent of the population.¹

• Incidence is higher in females, in the range of 4:1 to 5:1. Flare-ups may be associated with menses.¹

Etiology and Pathophysiology

• Disorder of the terminal follicular epithelium in the apocrine gland-bearing skin.¹

• Starts with occlusion of hair follicles that lead to occlusion of surrounding apocrine glands.

• Chronic relapsing inflammation with mucopurulent discharge.

• Can lead to sinus tracts, draining fistulas and progressive scarring.

Risk Factors

Obesity, smoking, and tight-fitting clothing.

Diagnosis

Clinical Features

• Most common presentation is painful, tender, firm, nodular lesions in axillae (Figures 98-1 and 98-2).

• Nodules may open and drain pus spontaneously and heal slowly, with or without drainage, over 10 to 30 days.¹

• Nodules may recur several times yearly, or in severe cases new lesions form as old ones heal.

• Surrounding cellulitis may be present and require systemic antibiotic treatment.

• Chronic recurrences result in thickened sinus tracts, which may become draining fistulas (Figures 98-3).

• HS can cause disabling pain, diminished range of motion, and social isolation.

Typical Distribution

• Axillary, inguinal, periareolar, intermammary (Figure 98-4), inframammary, pubic area (Figure 98-5), infraumbilical midline, gluteal folds, top of the anterior thighs, and the perianal region.¹

Laboratory Studies

Culture of purulence is likely to yield staphylococci and streptococci and is usually unnecessary to determine treatment. Culture may be useful if you suspect methicillin-resistant Staphylococcus aureus.

Differential Diagnosis

• Bacterial infections, including folliculitis, carbuncles, furuncles, abscess, and cellulitis, may resemble HS but are less likely to be recurrent in the intertriginous areas.

• Epidermal cysts in the intertriginous regions may resemble HS. Theses cysts contain malodorous keratin contents.

• Granuloma inguinale and lymphogranuloma venereum are sexually transmitted infections that can produce inguinal ulcers and adenopathy that could be mistaken for HS.

Management

• Lifestyle changes are recommended, including weight loss if obesity is present. SOR C

• Smoking is a risk factor for HS and cessation is highly recommended for many reasons.¹ See SOR B for HS and SOR A for other health reasons.

• Frequent bathing and wearing loose-fitting clothing may help.

Medical treatment is similar to acne treatment:

• Oral antibiotics are used in acute and chronic treatment. Oral tetracyclines, clindamycin, rifampin, and dapsone have been touted as beneficial. If there is methicillin-resistant S. aureus present, trimethoprim/sulfamethoxazole or clindamycin should be used.

• Doxycycline 100 mg bid can be used acutely and to prevent new lesions in the mildest of cases. Many patients do not find these antibiotics to be of great help. SOR C

• Topical clindamycin bid may be used in the mildest of cases. In one randomized controlled trial (RCT), systemic therapy with tetracyclines did not show better results than topical therapy with clindamycin.¹ SOR B

  • Combination of systemic clindamycin (300 mg twice daily) and rifampin (600 mg daily) is recommended for patients with more severe HS.^2,3 In a series of 116 patients, parameters of severity improved, as did the quality-of-life score.² In another study, 28 of 34 patients (82%) experienced at least partial improvement, and 16 (47%) showed a total remission.³ The maximum effect of treatment appeared within 10 weeks. Following total remission, 8 of 13 (61.5%) patients experienced a relapse after a mean period of 5 months. Nonresponders were predominantly patients with severe disease. The most frequent side effect is diarrhea.^2,3

  • Oral dapsone may be considered when other therapies fail. However, in one study only 38 percent of patients experienced improvement.⁴ SOR B Rapid recurrence after stopping treatment suggests that antiinflammatory effects may predominate over antimicrobial effects. The total effect appears to be smaller than that reported with combination therapy using clindamycin and rifampicin. The use of oral dapsone requires frequent monitoring of blood counts because it frequently causes hemolysis. A G6PD level should be checked first to make sure the patient is not at high risk for severe hemolysis.

• Isotretinoin can reduce the severity of attacks in some patients but is not a reliable cure for HS.⁵ SOR C Also it is a potent teratogen and best avoided for females with this indication.

• Acitretin can be an effective treatment for refractory HS. In one study, all 12 patients achieved remission and experienced a significant decrease in pain. Long-lasting improvement was observed in 9 patients, with no recurrence of lesions after 6 months (n = 1), 1 year (n = 3), more than 2 years (n = 2), more than 3 years (n = 2), and more than 4 years (n = 1).⁵ SOR B However, acitretin is an oral retinoid that causes birth defects and may remain in the body for 3 years. Therefore, it should be reserved for use in male adolescents only and strictly avoided in females of child-bearing potential.

• Antitumor necrosis factor (TNF) agents are being studied for severe, recalcitrant HS. In one series, infliximab therapy (weight based) was shown to be effective and well tolerated in 6 of 7 patients with HS who were resistant to previous therapy.⁶ This was in agreement with preexisting literature showing that 52 of 60 patients (87%) were improved after infliximab therapy.⁶ SOR B Adalimumab helps in the short-term, but no long-term curative effect was uniformly seen.⁷

• Intense pulsed light (IPL) with laser may be worth considering for patients who can afford the cost and time for treatment. In one study of 18 patients who were randomized to treatment of one axilla, groin, or inframammary area with IPL 2 times per week for 4 weeks, there was a significant improvement in the mean examination score, which was maintained at 12 months. Patients reported high levels of satisfaction with the IPL treatment.⁸ SOR B

Surgical treatments include the following:

• Intralesional steroids with 5 to 10 mg/mL of triamcinolone may help to decrease inflammation and pain within 24 to 48 hours. SOR C

• Incision and drainage of acute lesions are suggested for the large fluctuant abscesses that can occur in HS. Although this may give some relief of the pressure, the surgical treatment and repacking of the wound is painful, and there is no evidence that it speeds healing. SOR C

• Lancing small nodules is more painful than helpful and is not recommended.

• Surgical excision of affected area with or without skin grafting is used for recalcitrant disabling disease and should be individualized based on the stage and location of the disease.⁹ SOR B One surgical group has been using a medial thigh lift for immediate defect closure after radical excision of localized inguinal hidradenitis.¹⁰

Follow-Up

If there is cellulitis or a large abscess was drained, follow-up should be within days. Chronic relapsing disease can ultimately be managed with appointments every 3 to 6 months depending upon the treatment and its success.

Patient Education

Smoking cessation, weight loss if overweight, and avoidance of tight-fitting clothes.