Hidradenitis Suppurativa Treatments: Topical, Antibiotics, Pain Medications, Corticosteroids, Hormone Therapy, Biologics, Retinoids, Surgery

Hidradenitis suppurativa is a rare, chronic, and inflammatory skin condition that can appear in many forms. You may develop small, pimple-like bumps, boils, or deeper acne-like nodules. Hidradenitis suppurativa lesions are usually painful and affect those parts of the body where the skin rubs against each other, such as the groin, armpits, under the breasts, and the buttocks. After these lesions, you may develop tracts and scars under the skin. Hidradenitis suppurativa tends to worsen over time, and if you leave it untreated, it can significantly affect your quality of life. There is currently no cure for Hidradenitis suppurativa, but there are various medical and surgical options that help manage the symptoms. Here are some of the treatment options for hidradenitis suppurativa.

Overview of Hidradenitis Suppurativa

Hidradenitis suppurativa is a rare form of skin condition that affects different people in different ways. It can take on many forms, including boils, small, pimple-like bumps, or deeper acne-like nodules. Hidradenitis suppurativa is not a form of acne, but it is often referred to as acne inversa.(1,2,3,4,5,6)

This inflammatory skin condition is known to affect thousands of Americans and is often misdiagnosed, due to which people do not find relief from their symptoms.(7)

Hidradenitis suppurativa tends to affect those parts of the body where the rubs against skin, such as:

  • Buttocks
  • Armpits
  • Breasts
  • Inner thighs
  • Groin

The painful lesions of hidradenitis suppurativa are usually also filled with a foul-smelling fluid that can leak out without prior warning.

There is currently no cure for this rare skin condition. However, there are various medical and surgical treatment options that can help you manage your symptoms. These treatment options for hidradenitis suppurativa are approved by the United States and Canadian Hidradenitis Suppurativa Foundations and are a part of their clinical guidelines.(8)

If you have been diagnosed with hidradenitis suppurativa, or you suspect you might have this condition, it is helpful to educate yourself and be aware of all the available treatment options so that you can discuss with your doctor about which one will be the best for you.

Hidradenitis Suppurativa Treatments

Here are the different types of treatment options for hidradenitis suppurativa.

Topical Treatments for Hidradenitis Suppurativa

One of the most common treatments recommended for hidradenitis suppurativa is a topical treatment, meaning something you apply or use directly on the skin. Topical treatments usually include ointments, creams, and lotions.(9) Depending on the exact product you are using, topical treatments for hidradenitis suppurativa work to keep the affected area clean, alleviate irritation, and help in the healing of your lesions.(10) Topical treatments for hidradenitis suppurativa include products that are commonly used in acne treatments and antiseptic agents.(11) Some examples of topical treatments for hidradenitis suppurativa include:

  • Chlorhexidine
  • Resorcinol cream 15%
  • Zinc pyrithione

These topical treatments are usually used for mild to moderate eruptions of hidradenitis suppurativa. Even though these treatments do not actively treat the underlying cause of the condition, they do help alleviate some of the symptoms of the disease.

Antibiotics may also be used topically for treating hidradenitis suppurativa. One of the most effective antibiotics that is used include topical clindamycin (brand names Clinda-Derm, Cleocin T).(12,13)

However, there can be certain side effects of these topical treatments, including symptoms like itching, redness, or a burning sensation.

Treating Hidradenitis Suppurativa with Antibiotics

Oral and topical antibiotics are both used for treating hidradenitis suppurativa.

Topical Antibiotics for Hidradenitis Suppurativa

The most commonly used topical antibiotic is clindamycin for treating mild to moderate hidradenitis suppurativa. Available under the brand names of Clinda-Derm and Cleocin T, this ointment is prescribed to treat the infection, reduce inflammation, and also prevent the formation of new lesions.(14) Clindamycin may also help reduce the foul-smelling discharge that sometimes accompanies hidradenitis suppurativa infections.

A generally prescribed course of topical antibiotics may involve applying the lotion or cream to the hidradenitis suppurativa lesions twice a day. The duration of treating hidradenitis suppurativa with topical antibiotics varies from person to person and also depends on the severity of your symptoms.

Some of the side effects of using topical antibiotics may include the risk of antibiotic resistance and a mild burning sensation.

Oral Antibiotics for Hidradenitis Suppurativa

While some doctors may prescribe oral antibiotics for treating mild cases of hidradenitis suppurativa, they are usually prescribed for treating moderate to severe cases of hidradenitis suppurativa or when topical treatment has not worked or given relief in the symptoms.

Similar to topical antibiotics, oral antibiotics also help to treat the infection and reduce inflammation caused by the condition.

Some of the common oral antibiotics used for the treatment of infections caused by hidradenitis suppurativa include:

  • Clindamycin
  • Dapsone
  • Tetracycline antibiotics
  • Metronidazole (brand name Flagyl)
  • Rifampin (brand name Rimactane)
  • Moxifloxacin (brand name Avelox) (15)

These antibiotics need to be taken by mouth for at least 7 to 10 days. In some cases, they may need to be taken for more extended periods of time, depending on the severity of your condition. Depending on your symptoms, you may receive one antibiotic, or multiple antibiotics may be prescribed.

As with any medication, there can be side effects of taking oral antibiotics as well. A common side effect of oral antibiotics is diarrhea, rust-yellow to brownish color of the urine, and Clostridium difficile bacterial infection.

Pain Medications for Hidradenitis Suppurativa

Pain caused by hidradenitis suppurativa can stem from a variety of sources, including abscesses, scarring, and lesions. Due to this, pain management is an integral part of the treatment of hidradenitis suppurativa.(16)

The pain associated with hidradenitis suppurativa can differ in nature. For example, you can either have acute pain or chronic pain. In some cases, the pain may be accompanied by inflammation.

Here are some of the commonly used pain medications for hidradenitis suppurativa:

  • NSAIDs (non-steroidal anti-inflammatory drugs)
  • Acetaminophen (brand name Tylenol)
  • Lidocaine (brand name Ztildo)
  • Opioids
  • Anticonvulsants

Topical pain medications like lidocaine can sometimes also be used for treating acute hidradenitis suppurativa pain. This is applied directly to the affected area.

Nevertheless, oral pain medications are usually preferred for managing the pain caused by hidradenitis suppurativa. Some of the first-line pain medications include NSAIDs and acetaminophen, including naproxen (brand name Naprosyn) and ibuprofen (brand name Aleve and Advil).

If you find that first-line pain medications are not effective in managing your pain, you may be prescribed a short-term course of opioids like tramadol (brand name Ultram, ConZip) or more traditional opioids like morphine and codeine.(17)

In some cases, doctors may also prescribe certain anticonvulsants like pregabalin (brand name Lyrica) and gabapentin (brand name Neurontin) for relieving neuropathic pain.
There are a variety of side effects associated with many pain medications. For example, nausea and vomiting, stomach upset, and constipation. There is also a risk of addiction if you continue taking opioids for a longer period of time.

Corticosteroids for Hidradenitis Suppurativa

Corticosteroids can be prescribed for bringing down the swelling and inflammation and also for managing pain. These can be taken orally or administered through injection. Injected corticosteroids, known as intralesional corticosteroids, are usually used in mild cases. The injection is put directly at the affected area and helps lower the swelling and pain.

On the other hand, oral corticosteroids are used to treat moderate to severe cases of hidradenitis suppurativa. When these medications are taken orally, corticosteroids can have an effect on the entire body. This can help to clear up existing lesions and also help prevent the formation of new hidradenitis suppurativa lesions.

A short-term course of oral corticosteroids is used to manage a flare-up of your symptoms. In contrast, longer-term oral corticosteroids are used in managing severe cases that have not responded well to conventional treatments. However, in such cases, the lowest dose of corticosteroids are usually prescribed.(18)

There can be various side effects of corticosteroids. For example, injected corticosteroids can cause pain near the injection spot, insomnia, and facial flushing. Some of the potential side effects of oral corticosteroids include weight gain, high blood pressure and mood swings. Long-term use of corticosteroids for treating hidradenitis suppurativa may cause high blood sugar, osteoporosis, and skin thinning.

Treating Hidradenitis Suppurativa with Hormone Therapy

Hidradenitis suppurativa is believed to be influenced and aggravated by hormones known as androgens. Hormonal changes in women, especially during pregnancy, before menopause, and during the menstrual cycle, may worsen the symptoms of hidradenitis suppurativa. Because of the effect of hormones on the progression of this disease, doctors sometimes recommend hormone therapy for treating hidradenitis suppurativa.

Hormone therapy may help reduce pain and also decrease the amount of fluid draining from the lesions, especially during a flare-up.

Hormone therapy for hidradenitis suppurativa usually involves taking the following types of medications:

  • Oral contraceptives that contain estrogen
  • Metformin (brand name Glumetza)
  • Finasteride (brand name Proscar and Propecia)
  • Spironolactone (brand name Aldactone)

Hormone therapy for treating hidradenitis suppurativa is taken orally. While you are on hormone therapy for mild to moderate hidradenitis suppurativa, you will be prescribed only monotherapy, which means you will only be on hormone therapy. However, in severe cases of hidradenitis suppurativa, you may be prescribed hormone therapy combined with other treatment options.

In most cases, the use of oral contraceptives that only contain progestin is avoided because there is some anecdotal evidence that hidradenitis suppurativa tends to worsen when using progestin-only medication.(19)

Potential side effects of hormonal therapy in women can include the formation of blood clots in taken during pregnancy. Men may experience reduced libido and have problems in ejaculation. In some rare cases, both men and women may develop breast tumors as a side effect of hormone therapy.(20,21)

Treating Hidradenitis Suppurativa with Biologics

In the severe cases of hidradenitis suppurativa that have not responded to hormone therapy or antibiotics, biologic medications may be recommended. Biologics are a class of drugs that help your body fight against hidradenitis suppurativa by targeting the specific parts of the immune system that stimulate inflammation.(22,23)

These medications are usually administered through an intravenous infusion or an injection. They are commonly taken on a weekly basis and can be given either at the hospital/clinic or at home by a medical professional.

The only biologic that has been approved for the treatment of hidradenitis suppurativa by the US Food and Drug Administration, and has the strongest proof to be effective in treating this condition, is adalimumab (brand name Humira).(24)

Other biologics like anakinra (brand name Kineret) and infliximab (brand name Remicade) may also be useful in treating hidradenitis suppurativa, but more research is still needed in establishing their effectiveness.

Potential side effects of using biologics for treating hidradenitis suppurativa include:

  • Fever
  • Pain at the injection site
  • Increased risk of infections
  • Low blood pressure
  • Difficulty breathing

If you develop an infection while taking a biologic drug, your doctor is likely to discontinue using biologics and look at other treatment options. Though it is rare, some of the severe side effects of biologics include autoimmune nerve symptoms and heart failure. Biologics are also associated with a greater risk of lymphoma. If you have severe hidradenitis suppurativa and would like to explore biologics as a form of treatment, you should talk to your doctor about the various pros and cons of this form of treatment.

Treating Hidradenitis Suppurativa with Retinoids

Retinoids are a type of medication that is processed from vitamin A. They work by reducing inflammation and slowing down the growth of the skin cells. Retinoids are already used to treat a wide variety of inflammatory skin conditions like psoriasis and acne.

Oral retinoids are believed to be more helpful for some people with hidradenitis suppurativa. If you have been prescribed an oral retinoid for hidradenitis suppurativa, it is likely to be one of these two:

  • Acitretin (brand name Soriatane)
  • Isotretinoin (brand names Claravis and Amnesteem)

Oral retinoids are usually only prescribed as a second or third-line of treatment for hidradenitis suppurativa.(25) They may also be recommended in cases where there is severe acne along with the lesions of hidradenitis suppurativa.

You cannot take oral retinoids if you are pregnant as they may cause severe congenital disabilities. Some other side effects of oral retinoids may include cracked lips, dry skin, and temporary hair loss.(26)

Surgical Treatments for Hidradenitis Suppurativa

There is a variety of surgical treatment options that are available for treating hidradenitis suppurativa. These include minor incisions to complete removal of the part of the skin affected by hidradenitis suppurativa lesions. However, whether or not you are eligible for such surgical options depends on the severity of your hidradenitis suppurativa and how well you have responded to the other forms of treatment.

People who have severe hidradenitis suppurativa and have not found relief from other forms of treatment are usually the ones who make good candidates for surgery. The symptoms of severe hidradenitis suppurativa include:

  • Scarring
  • Widespread abscesses or lesions
  • Numerous connecting tunnels underneath the skin

Here are some of the surgical techniques that may be used for treating severe hidradenitis suppurativa include:

Excision: In this technique, the surgeon will remove the hidradenitis suppurativa lesion along with some of the nearby healthy skin. This is usually carried out with a scalpel, laser, or other electrosurgical tool. It is used in cases where there are extensive and recurring lesions.(27)

Deroofing: In this technique, the surgeon removes the tissue present above the abscesses or tunnels and then allows the exposed area to heal. This surgical method is usually used for recurring tunnels or lesions.(28)

Excision and drainage: In this method, the surgeon drains one or two lesions and removes them. This is only done to provide short-term relief for the abscessed lesions.(29)

Some of the side effects of surgery for hidradenitis suppurativa include infection or scarring at the surgical site. Also, since surgery only treats a certain area, it is possible for lesions to appear at new locations.

After you undergo surgery for hidradenitis suppurativa, it is very important to take proper care of your wound. Your doctor will choose an appropriate dressing option for the wound based on the extent and location of the surgery. You will also be told to use an antiseptic wash during the healing process. Avoid clothes that may rub against the wound until it heals, and keep a careful watch for any signs of an infection.

Conclusion

There are many treatments for hidradenitis suppurativa, with each having its own benefits and potential side effects. The treatment or combination of treatments that may be recommended for you by your doctor will depend on the severity of your symptoms. It is important that you thoroughly go over your treatment options with your doctor to know about the potential benefits and side effects. Make sure to inform your doctor about any side effects that you may experience while under treatment. Do not start any new medications or stop your current treatment without consulting your doctor.

References:

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  26. Boer, J., 2006. Oral retinoids for hidradenitis suppurativa. In Hidradenitis suppurativa (pp. 128-135). Springer, Berlin, Heidelberg.
  27. Rompel, R. and Petres, J., 2000. Long‐term results of wide surgical excision in 106 patients with hidradenitis suppurativa. Dermatologic surgery, 26(7), pp.638-643.
  28. van der Zee, H.H., Prens, E.P. and Boer, J., 2010. Deroofing: a tissue-saving surgical technique for the treatment of mild to moderate hidradenitis suppurativa lesions. Journal of the American Academy of Dermatology, 63(3), pp.475-480.
  29. Kagan, R.J., Yakuboff, K.P., Warner, P. and Warden, G.D., 2005. Surgical treatment of hidradenitis suppurativa: a 10-year experience. Surgery, 138(4), pp.734-741.

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