TREATMENTS USED FOR HIDRADENITIS
Treatments for HS can be divided into 1) those therapies focused on the single area of activity, 2) those therapies designed to reduce the inflammation of multiple areas, 3) those therapies attempting to get rid of the scars and sinus tracts, and 4) those therapies hoping to prevent the development of new lesions.
TREATMENT FOR THE SINGLE, PAINFUL LESION
In treating a single new lesion, the goal is to reduce acute discomfort and inflammation. Early care-givers noted that incision and drainage would almost immediately improve the discomfort of painful pressure within the lesion; however there was frequently scarring, recurrence, and new sinus tract formation that would develop along the path of the incision. Antibiotics were often used, originally with the thought of treating “the infection”. As we now know however, these areas were only rarely infected, and the useful antibiotics would act primarily as inflammation-reducers. Systemic antibiotics such as the tetracycline family, sulfas, erythromycins, clindamycin and rifampin were all noted to be helpful in acute flares. More recently, antibiotics have been combined with steroids and given as shots within the inflamed nodule; this continues to be an effective means of reducing the acute signs and symptoms of the nodule but do not prevent recurrence. Warm tap water compresses may give some symptomatic relief, but give little help to the overall process.
TREATMENT FOR MULTIPLE LESIONS
For the individual with multiple, often recurring areas, treatment of individual nodules may be inadequate. Ongoing therapies such as continuous antibiotics or other continuous anti-inflammatory medications may be helpful. Topical or oral antibiotics, and even topical benzoyl peroxide therapies may be helpful in reducing flares. Recently combinations such as the mix of oral clindamycin and rifampicin have been reported to have some benefits, although with some risk of significant side effects such as diarrhea.
Other anti-inflammatory therapies may also be helpful. The use of oral dapsone (avlosulfone) has been helpful in some patients. Also the use of the new category of anti-inflammatory medications, the biologics or tumor necrosis factor (TNF-alpha) inhibitors, has been associated with a degree of improvement in some patients. Medications such as infliximab (Remicade@), etanercept (Embrel@), and adalimumab (Humira@) have all been used, with mixed results. Potential side effects of these medications mandate that they be used with caution.
Since the presence of adult hormones appears to be important in the cause of the condition, hormonal therapies have been used. Avoiding certain foods which may contribute to the development of male-like hormones has been suggested. Medications used to block the hormone pathway at the level of the follicle may also be helpful. Cyproterone acetate, spironolactone, and finasteride have all been used with varying degrees of benefit.
Because the follicular events seen in acne and HS appear to be so similar, a powerful and effective acne treatment has also been attempted for HS. The retinoid (Vitamin A derivative) isotretinoin (Accutane@) has been studied in HS therapy. However results have been inconsistent, and in our experience, not very successful. Other retinoids such as Acetretin/Soriatane@ may have greater effects, but have significant side effect potentials.
Lasers have been used to try to reduce the acute inflammation and flare-ups. Improvement has been noted using the 1064-nm Nd:YAG (neodynium YAG) laser. In addition, non-ablative radiofrequency or 1450-nm diode lasers have been reported to be helpful. Photodynamic therapy, whereby a medication is concentrated within lesions of HS followed by a light exposure to the lesions has produced inconsistent and non-lasting results.
TREATMENT FOR TUNNELS/SINUS TRACTS
In our experience, once tunnels have formed, anti-inflammatory therapies of all types will produce only temporary improvement. Until/unless the sinus tracts and scars are removed, inflammation will recur as the dose of anti-inflammatory agents is reduced or discontinued. Lasting improvement will therefore be noted only by removing the tunnels and scars. This may be performed by excising the troublesome area(s). Removal has historically been followed by suturing, or skin grafts or flaps to cover the defects. Unfortunately, these approaches have usually required that the surgery be performed in the operating suite, using general anesthesia, and requiring post-operative hospital confinement. In addition, recurrences have been common, approaching 40-70 %.
OUR TREATMENT FOR PERSISTENT OR TUNNEL AREAS OF HS
For a number of years we have been using a technique of “carbon dioxide laser excision and marsupialization” to treat persistent individual lesions, as well as intercommunicating tunnels. We have found that removal using a carbon dioxide laser has allowed the surgeon to identify and remove sinus tracts and extensions that would not otherwise be visible. As such, complete removal has been more successful than with other methods. Indeed we previously reported our results wherein there were only 2 recurrences in 185 areas treated. Follow-up in our patients averaged over 4 years and ranged from 1-17 years. Since our original publication, many additional patients have been treated, with a total of 332 areas treated and 6 recurrences (1.8% incidence) as of July, 2011.
The technique we have found to be effective is as follows. Patients can be treated in the office setting. A topical anesthetic is applied to reduce surface discomfort, followed by a local anesthetic injection to produce more complete comfort to the affected area. General anesthetic is not normally needed. The CO2 laser is then used to cut around and under any areas of tunneling, scars or inflammation. Generally, the depth is in the deep dermal layer (where the hair follicles reside), so that it is not normally necessary to enter muscles. By examining the interior of the surgical site, it is possible to discover hidden tunnels of affected skin – the presumed reason why so many other approaches fail. All affected tissue is thereby removed, and the laser then used to produce a smooth interior wound. Total time for the procedure is normally 2 ½ -3 hours. Wound healing takes place naturally, initially filling in the depth of the area, and subsequently healing the surface skin. Because no muscle is disturbed, healing is generally comfortable, with only a surface dressing and daily bandage change. Healing is usually complete after 8-10 weeks. Qualities of healing have been acceptable to excellent, and no patient has required scar revision.
Complications from the CO2 laser approach have generally been rare. The main inconveniences are: 1) that there is a limitation on the size of the area which may be treated at one session and 2) that healing will be gradual, normally over a period of weeks. Treating too large an area at one session may require quantities of local anesthetic which could be unsafe. Also, since the size of the area to be treated will influence the convenience of the patient post-operatively, larger areas will be more challenging for care. For both reasons, a substantial area will occasionally be completed in two sessions. Similarly, the individual with multiple areas will also often require multiple sessions. Again, the advantages of performing the surgery in the outpatient setting, with local anesthesia, with no hospital stay, and with good comfort postoperatively have made this approach an attractive option to many patients.
Other complications must also be considered. Bleeding, discomfort, delayed healing, infection, scarring and recurrence are all possible but are uncommon.
TOTAL HS MANAGEMENT
One of the frustrations of HS is that new areas may appear, even if old areas remain clear. For many patients, medical efforts to prevent new lesions should be coupled with resolution of old areas. A key focus of our research is the question of how to prevent the ongoing nature of the process.