(lacking parakeratosis) and subepidermal perifollicu-
5
lar collections of lymphocytes also have been
observed in early disease.24 More mature lesions may
exhibit noncaseating granulomas, abscesses,
epidermal cysts, sinus tracts, granulation tissue, and
dermal fibrosis.27,87 Subcutaneous inflammation,
fibrosis, and fat necrosis also can be observed.
Apocrinitis may occur by exten- sion; however,
apocrine gland involvement is seen in 12% to 30% of
cases.27,85,87 However, secondary inflam- mation of the
eccrine glands is more often present (19% to 32% of
cases).27,85,87 Primary inflammation of the apo- crine
glands is rare, occurring in 5% of lesions.27,85,87
Acutely, the inflammatory infiltrate is largely com-
prised of T-lymphocytes and neutrophils at the follicu-
lar epithelium with variable extension into the
adnexal structures.24 A histopathologic analysis of
surgical speci- mens found a marked CD8+ T-
lymphocyte epitheliotro- pism in the follicular and
subepidermal inflammatory infiltrates of early HS
lesions.24 The ratio of CD8+ cyto- toxic T-lymphocytes
to CD4+ helper T-lymphocytes also appears to increase
over the lifetime of active lesions.86 In chronic lesions,
lymphocytes, histiocytes, and multinucleated giant
cells predominate, generating foreign-body
granulomas around ruptured hair follicles and skin
adnexa.88 Eosinophils and plasma cells are also seen
on occasion.87 Notably, recent immunohistochem- istry
studies report elevated IL-17 and IL-23 expression
along with distinct dermal infiltrates of Th17 helper
T cells within lesional and perilesional skin.49,52
CLINICAL COURSE AND
PROGNOSIS
Disease onset is typically after puberty, with a
reported age range from 16 to 81 years.4 Because HS
can resem- ble other pustular dermatoses, delays in
diagnosis of 7 to 12 years are not uncommon. 89 In one
cross-sectional survey, patients reported having 4.6
painful boils per month, with each boil lasting an
average of 6.9 days.90 Mean duration of disease was
18.8 years, with the most-severe symptoms occurring
early in the disease course (after a mean of 6.4 years
from disease onset).90 Disease activity generally
declines after 50 years of age.38 Remissions are
significantly more likely in non- smokers, those who
have quit smoking, and in non- obese individuals.41
MANAGEMENT
HS is a complex, heterogeneous disease with
unpredict- able responses to therapy. Therefore, formal
treatment guidelines for HS do not exist, and
therapeutic decisions are generally guided by disease
severity. Hurley stage I disease (mild) is typically
amenable to medical therapy alone; Hurley stage II
disease (moderate) may require both medical therapy
and localized surgical excisions; Hurley stage III
disease (severe) often requires exten- sive, wide
excisional surgical procedures with advanced grafting
and flap procedures. There is no cure for HS. The
overall goals of therapy are to prevent formation
of primary lesions and to reduce the impact of disease
sequelae (eg, fibrosis, contractures, sinus tracts) on
qual- ity of life. Tables 84-4 and 84-5 and Fig. 84-11
offer a pro- posed management algorithm.
IFESTYLE MODIFICATIONS AND
HOME REMEDIES
Smoking cessation and weight management are
important components of symptom mitigation at all
stages of disease. Nonsmokers achieved a higher rate
of remission (40%) than active smokers (29%) over
a mean followup period of 22 years. 41 Rates of new
lesion formation following excisional surgery were
lower among those who ceased smoking versus those
Ch
who continued smoking.42 Weight loss of 15% or more
ap
from baseline after bariatric surgery was also associ-
ter
ated with a 20% reduction in number of active, erup-
84
tive sites.41
::
Conservative measures, such as stress reduction,
warm baths, warm compresses, and hydrotherapy, Hi
may help alleviate symptoms.91 Taking “bleach baths” dr
(ie, one-quarter cup of regular bleach diluted in a full ad
tub or 40 gallons of water) and/or washing the eni
affected areas with topical cleansing agents (eg, tis
chlorhexidine gluconate or benzoyl peroxide solution) Su
2 to 3 times per week can reduce bacterial load and pp
decrease malodor.9 Resorcinol 10% to 15% cream, a ur
topical peeling agent traditionally used for acne, can ati
improve pain and reduce the duration of painful va
abscesses.92 Dressings are useful for managing
drainage, decreasing malodor, and protecting apparel
from stains. Wound dress- ings are sometimes
covered by insurance; abdominal (eg, ABD) gauze
pads and sanitary pads can be used as alternatives.
Short courses of nonsteroidal antiin- flammatory
drugs can help alleviate pain and reduce
inflammation.
Patients should be counseled to avoid tight cloth-
ing, prolonged exposure to heat and humidity, and
shaving, if these are noted as triggers.90 Consump-
tion of insulinotropic milk and dairy products, as
well as hyperglycemic foods, upregulate the PI3K/
Akt-signaling pathway, leading to nuclear defi-
ciency of FoxO1 transcription factor.93,94 Deficiency
in FoxO1 is thought to play a role in acne vulgaris
and acne-like eruptions. 94 Further research is needed
in this area, but decreasing exposure to dairy and
high-glycemic-index foods may be an adjunct to
medical therapy, either directly or indirectly, by pro-
moting weight loss.
Applying minced turmeric root as a poultice to
active sites or ingesting diluted turmeric (1 teaspoon
of turmeric powder diluted in one-quarter cup liquid)
3 times daily has had anecdotal success in ameliorat-
ing symptoms. Curcumin, the active ingredient in tur-
meric, may help reduce inflammation via suppression
of TNF-.95
A 6-month course of high-dose zinc gluconate
1487
supplementation (90 mg daily, tapered by 15 mg
every 2 months) improved clinical status in a cohort
 TABLE 84-4
Ratings of Select Therapies for Hidradenitis Suppurativa Based on Category of Evidence and Strength of
Recommendation
THERAPY CATEGORY OF EVIDENCE STRENGTH OF RECOMMENDATION

First-line
Clindamycin (topical)a
IIb Possible
Clindamycin/rifampicin (oral)b
III BC
Adalimumab (subcutaneous)c
I A
Tetracycline (oral) IIb B
Second-line
Zinc gluconate
III III C
Resorcinol (cream)
IV IV C
Intralesional corticosteroid Ib/II D
Pa Systemic corticosteroid a D
rt Infliximab III B
Acitretin/etretinate
15 C
:: Third-line
Colchicine
IV D
Botulinum toxin (subcutaneous)
IV D
Dis Isotretinoin
IV D
or Dapsone
IV D
Cyclosporine
de IV D
Hormones
rs IV D
Surgery
of Excision or curettage of individual
Ec III C B
lesions
Total excision of lesions and surrounding hair-bearing
IIb B C
cri skin
Secondary intension healing
IIb C
ne Primary closure
III III A/
an Reconstruction with skin grafting and negative pressure wound
Ia/II BD
therapy
Reconstruction with flap plasty
d a IV A
Deroofing AD
Ap CO2 laser therapy
Ib
Ib IV
oc Neodymium:yttrium-aluminum-garnet (Nd:YAG)
rin laser pulsed light
Intense
e Pain Control
Sw Nonsteroidal antiinflammatory drugs
IV D
ea Opiates
IV D
t Dressings
Dressings
No No
studies have
studies been
have published
been as of
published as this writing
of this on on
writing thethe
useuse
of specific
of IV
V D
specific
dressings or or
dressings wound
woundcare
caremethodology
methodologyininhidradenitis
hidradenitis suppurativa; choice
suppurativa; choice
of
of dressing
dressing is based
is basedononclinical
clinical experience
experience
a
Single double-blind, placebo-controlled, randomized trial. Hurley stages I to II.
b
Evaluated in case series.
c
Multiple prospective, randomized, double-blind, placebo-controlled trials (Pioneer 1 and 2).
Adapted from Gulliver W, Zouboulis CC, Prens E, et al. Evidence-based approach to the treatment of hidradenitis suppurativa/acne inversa, based
on the European guidelines for hidradenitis suppurativa. Rev Endocr Metab Disord. 2016;17(3):343-351, with permission.

TABLE 84-5
Category of Evidence/Strength of Recommendation Grading Scale
CATEGORY OF EVIDENCE STRENGTH OF RECOMMENDATION

Ia: Metaanalysis of randomized controlled A: Category I

trials evidence
Ib: Randomized controlled trial
IIa: Controlled study without B: Category II evidence or extrapolated from category I
randomization evidence
IIb: Quasiexperimental study
III: Nonexperimental descriptive studies such as C: Category III evidence or extrapolated from category I or II
comparative, evidence
correlation, and case-control studies
IV: Expert committee reports or opinion or clinical D: Category IV evidence or extrapolated from category II or III
IV: Expert committee
experience of reports or opinion or clinical D: Category IV evidence or extrapolated from category II or III
evidence
experience ofauthorities, or
respectedauthorities, evidence
respected or both
both
1488 Data from Guyatt G, Oxman AD, Vist GE, et al. GRADE: An emerging consensus on rating quality of evidence and strength of recommendations. BMJ.
2008; 336:924; and from Gulliver W, Zouboulis CC, Prens E, et al. Evidence-based approach to the treatment of hidradenitis suppurativa/acne
inversa, based on the European guidelines for hidradenitis suppurativa. Rev Endocr Metab Disord. 2016;17(3):343-351, with permission.
5