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Hidradenitis suppurativa is a chronic immune mediated disease of universal distribution that causes great damage to the quality of life of the affected individual, whose prevalence is estimated at 0. The objective of this work was update on physiopathogenesis, diagnosis and classification of hidradenitis suppurativa and to establish therapeutic recommendations in the Brazilian reality.
It was organized as a work group composed of eight dermatologists from several institutions of the country with experience in the treatment of hidradenitis suppurativa and carried out review on the topic. Recommendations were elaborated and voted by modified Delphi system and statistical analysis of the results was performed.
The Brazilian consensus on the clinical approach of hidradenitis suppurativa had the support of the Brazilian Society of Dermatology. Keywords: Anti-bacterial agents; Antibodies, monoclonal; Consensus; Hidradenitis suppurativa. Actas Dermosifiliogr. In Brazil, the prevalence is 0. Prevalence of hidradenitis suppurativa in Brazil: a population survey. Int J Dermatol. The objective of this consensus is to inform the physician about HS and provide recommendations on its treatment according to the Brazilian context.
Consensus on the management of patients with psoriatic arthritis in a dermatology setting. J Eur Acad Dermatol Venereol. The differences in practice between men, women, adults and children are also one talking point.
To prepare this consensus, a work group made by eight dermatologists was formed with the support of the Brazilian Society of Dermatology, who are experienced in the clinical and surgical treatment of patients with hidradenitis suppurativa, representing the many regions of the country. A systematic review of the clinical treatment of hidradenitis suppurativa and a survey of therapeutic guidelines were performed.
The remaining were re-evaluated, re-discussed and re-posted for voting for the second time. Data obtained were analyzed statistically. Actas Dermassifiliogr.
The use of ranks to avoid the assumption of normality implicit in the analysis of variance. Journal of the American Statistical Association. Data were arranged into tables with levels of evidence Center of Based Evidence Oxford , grades of recommendation and degree of agreement among the specialists. Oxford: CEBM; Hidradenitis suppurativa is a chronic, recurrent inflammatory condition of the hair follicle, that occurs in genetically predisposed individuals and is influenced by environmental factors such as smoking and obesity.
It causes a great impact in the quality of life with physical, psychological and socioeconomic sequelae. Sex steroids seem to influence the course of the disease with onset after puberty, female predominance and perimenstrual exacerbation; however, their contribution to the pathogenesis is still unclear. Update on hidradenitis suppurativa: connecting the tracts. FPrime Rep. Inflammatory Mechanisms in Hidradenitis Suppurativa. Dermatol Clin.
Pathophysiology of hidradenitis suppurativa : An update. J Am Acad Dermatol. Hidradenitis suppurativa can be associated to many diseases, such as follicular occlusion syndrome acne conglobata, dissecting cellulitis and pilonidal sinus ; auto-inflammatory diseases such as SAPHO synovitis, acne, pustulosis, hyperostosis and osteitis , PASH pyoderma gangrenosum, acne and suppurative hidradenitis and PAPASH pyogenic arthritis, pyoderma gangrenosum, acne and suppurative hidradenitis syndromes and genetic syndromes, the most prevalent being Down and KID keratosis, ichthyosis, deafness syndromes.
It is also frequently associated to inflammatory bowel disease and spondyloarthropathies. It can be accompanied by manifestations of neutrophilic conditions such as pyoderma gangrenosum, Sweet syndrome and erythema nodosum. Psychiatric conditions are highly prevalent in HS patients, such as depression and suicidal ideation.
More than half of the patients are obese and present features of metabolic syndrome, including insulin resistance and polycystic ovary syndrome, which are more prevalent in affected females. Comorbidities of hidradenitis suppurativa acne inversa. Systemic associations of hidradenitis suppurativa. Prevalence, risk factors, and comorbidities of hidradenitis suppurativa. The prevalence of metabolic syndrome in patients with hidradenitis suppurativa.
HS patients are under a higher risk of early severe cardiovascular events and reduced life expectancy than patients with psoriasis and other severe inflammatory diseases. Risk of major adverse cardiovascular events and all-cause mortality in patients with hidradenitis suppurativa. JAMA Dermatol. The dermatologist should be vigilant and inquire about possible symptoms of these entities joint pains, bone pains, intestinal symptoms, sexual dysfunction, psychiatric symptoms so that the approach to the HS patient be comprehensive.
Quality of life impairment in hidradenitis suppurativa: a study of 61 cases. Diagnosis is clinical in essence, based on the modified criteria of Dessau. For such, it is important to define lesions and typical sites besides recurrence or chronicity, translated by the occurrence of 2 or more episodes in 6 months.
For didactic purposes, this consensus suggests the following description for HS lesions:. Abscess-like: painful, fluctuant lesion larger than 1 cm in diameter, with an inflammatory aspect, not necessarily septic.
Tunnel: longitudinal, raised, painful, fluctuant mass, with variable length and depth, ending on the skin surface and occasionally with fluid discharge pus, blood, serum. This denomination includes fistulas, draining and non-draining sinus tracts. Typical sites are axillae, inguinal regions, inframammary region and intermammary and gluteal clefts, even though atypical sites can also be involved face, neck, back, thighs. Hidradenitis suppurativa: viewpoint on clinical phenotyping, pathogenesis and novel treatments.
Exp Dermatol. Complementary exams such as biopsy and culture of the lesions are indicted in cases of diagnostic uncertainty. Recalcitrant Hidradenitis Suppurativa: An investigation of demographics, surgical management, bacterial isolates, pharmacologic intervention, and patient-reported health outcomes. Am Surg. Suspicious chronic lesions can also require malignancy screening. Squamous cell carcinoma in the setting of chronic hidradenitis suppurativa; report of a patient and update of the literature.
Dermatol Online J. Ultrasound evaluation can contribute to post-surgery follow-up if recurrence is suspected. Dermatol Surg. Treat syndromic cases, in which HS is associated to other conditions such as auto-inflammatory diseases and inflammatory bowel disease. To define the treatment to be established, is important to recognize elementary lesion and adequately classify HS.
Many classifications were proposed, but the following classifications were chosen to guide this consensus due to their practicality and ease of use:. This system was recently developed and validated by members of the European Hidradenitis Suppurativa Foundation and consists in a simple evaluation that better reflects the severity of the clinical picture:.
The total value is stratified as mild score of 3 or less , moderate score of 4 to 10 and severe score of 11 or more. Br J Dermatol. This scale was developed with the purpose of being a parameter of evaluation of the clinical response to treatment. The definition proposed of response to treatment i.
Assessing the validity, responsiveness and meaningfulness of the Hidradenitis Suppurativa Clinical Response HiSCR as the clinical endpoint for hidradenitis suppurativa treatment. Besides the severity assessment indexes, hidradenitis should be understood according to its clinical features that can influence the treatment choice.
Canoile-Poitrine classification groups cases into axillary-mammary, follicular and gluteal types. Identification of three hidradenitis suppurativa phenotypes: latent class analysis of a cross-sectional study. J Invest Dermatol. New insights into the diagnosis of hidradenitis suppurativa: clinical presentations and phenotypes. There are studies correlating obesity with the course and severity of HS. The influence of obesity in the process of systemic inflammation and risk of comorbidities is known.
In the case of HS, obesity influences the disease directly through mechanical effects friction, rubbing of the hair shaft and the coexistence of hormonal changes polycystic ovary syndrome and glucose intolerance.
In view of these considerations, weight loss is recommended in the approach of the patient with HS, with or without disease activity. Resolution of hidradenitis suppurativa after weight loss by dietary measures, especially on frictional locations. Rapid resolution of hidradenitis suppurativa after bariatric surgical intervention. Clin Exp Dermatol. The influence of body weight on the prevalence and severity of hidradenitis suppurativa. Acta DermVenereol. It is not common to ask about pruritus when seeing patients with HS.
However, great part of the patients complain of pruritus that can even impair sleep and, consequently, the quality of life. Studies demonstrate that pruritus, as erythema and local pain are considered prodromal symptoms for flares. Pruritus control is recommended with or without disease activity, with the primary goal of improving the quality of life of these patients. Am J Clin Dermatol. Prodromal symptoms in hidradenitis suppurativa.
Even though there are no randomized studies establishing the causal relationship between smoking and HS, many studies point to a high prevalence of smoking among HS patients, besides increased severity of the disease in those who smoke. Tobacco seems to influence the genetic predisposition for HS, leading to the formation of follicular plugs and the inflammatory process triggered by neutrophils. Smoking cessation is important in the approach of the patient with HS.
Objective scoring of hidradenitis suppurativa reflecting the role of tobacco smoking and obesity. Cigarette smoking as a triggering factor of hidradenitis suppurativa. Risk factors, clinical course and long-term prognosis in hidradenitis suppurativa: a cross-sectional study. Hidradenitis suppurativa.
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It is important to emphasize that HS lesions have a self-limited course. The rational use of topical antibiotic is a growing concern due to the risk of bacterial resistance. Clin Ther.
Addressing resistance to antibiotics in systematic reviews of antibiotic interventions. J Antimicrob Chemother. Patterns of antimicrobial resistance in lesions of hidradenitis suppurativa. The association with other topicals such as benzoyl peroxide or replacement with resorcinol are a good strategy to minimize the risk.
Sulfa and tetracycline substances were indicated as first choice. For women of childbearing age, the choices according to the order of preference were: sulfas, tetracyclines, oral contraceptive, systemic steroid, metformin, isotretinoin, clindamycin plus rifampicin, zinc and finasteride. The use of acitretin demands caution due to the risk of teratogenesis.
The results demonstrated that preferences are not similar among specialists. There must be caution with the use of rifampicin. Development of resistance to Mycobacterium tuberculosis is manageable in hidradenitis suppurativa. Response to treatment of hidradenitis suppurativa with rifampicin: have we forgotten tuberculosis?
These infectious diseases should be screened before starting the treatment. Rifampicin is a first-line drug for the treatment of tuberculosis. The incidence of tuberculosis cases resistant to polychemotherapy has increased worldwide and particularly in countries where the disease has a high prevalence, according to an alert from the World Health Organization WHO. The association of other antibiotic regimens such as clindamycin and ofloxacin can have similar efficacy.
Systemic treatment with clindamycin plus ofloxacin can be indicated in cases of moderate to severe HS as second-line antibiotic therapy. There was an The course of antibiotic therapy should be long, for at least 10 to 12 weeks and with optimized doses.
It can be associated with or followed by other medications with an anti-inflammatory or antiandrogen effect. Other immunomodulators such as dapsone, for example, can be considered as maintenance therapy for cases with frequent flares, avoiding or delaying the repeated use of antibiotics. Systemic steroids can initially contribute to reduce the inflammation but its prolonged use should be avoided due to adverse events and the risk of disease rebound. Oral retinoids can be an option for the forms associated with acne or clinical forms folliculitis-type.
Acitretin was shown to be more effective than isotretinoin but it has restrictions in women of childbearing age. Patients with moderate to severe hidradenitis suppurativa can be treated with anti-TNF-alpha biologic drugs.
These medications can be used in association with surgical treatment of cutaneous lesions. In the forms exceptionally severe associated to other conditions, biologic drugs can be indicated for the control of the manifestations even if the others are under control, prioritizing the treatment of the patient as a whole and not of the manifestations individually.
For all these statements, the concordance among the specialists was of Biologics are alternatives for recurrent cases that do not respond or respond partially to the first interventions. When there is considerable tissue damage, the clinical treatment cannot revert the tissue changes, that becomes a site of recurrent inflammation and secondary infection. Surg Cosm Dermatol. Skin Appendage Disord. Biofilms can form inside the tunnels, which are sometimes epithelialized in their interior, maintaining the inflammatory features of the disease.
A literature review showed that biofilms are implicated in many dermatological conditions, prevent wound healing and cause recurrent infections. The increasing relevance of biofilms in common dermatological conditions. Surgery for HS is a challenge for the dermatological surgeon since there are controversies regarding the appropriate technique, extension and reconstruction of the area excised.
It is important that the inflammatory process be minimum to demarcate the limits of the lesions and improve surgical and postoperative conditions. Deroofing, a technique described by Mullins in , can be performed for localized disease and consists in the removal of the roof of the tunnel using scissors, blade, electrosurgery or CO 2 laser, directed by a probe, leaving the clean wound bed to heal for secondary intention.
It is a simple technique that allows for speedy recovery and can be performed in the outpatient setting. Deroofing: a tissue-saving surgical technique for the treatment of mild to moderate hidradenitis suppurativa lesions. The risk of recurrence is higher with partial simple excision than with wide excision. Surgical approach to extensive hidradenitis suppurativa.
Surgical planning should be evaluated case by case, and it is not always possible to remove the whole affected tissue in one single step. Tumescent anesthesia, sedation or general anesthesia should be considered for wide excisions. In chronic cases, wide excision of the affected area yields better results and lower chances of local recurrence.
Removal of all tissues affected should be performed including dermis and subcutaneous tissue and sometimes including the underlying fascia, down to where the lesions extend, besides 1 to 2cm lateral margins.
Hidradenitis suppurativa: surgical and other management techniques. Recurrence after surgical treatment of hidradenitis suppurativa. Long-term results of wide surgical excision in patients with hidradenitis suppurativa. Reconstruction is the real challenge and the rule of simplification also applies to HS surgery. Therefore, secondary intention healing, primary closure, grafts and flaps are considered, in this order.
Secondary intention healing has advantages because it reduces the time for surgery and provides good cosmetic and functional results, even though the recovery time is longer.
Vacuum therapy V. C and special dressings contribute to a quicker resolution of the surgical wound. However, in certain situations, coverage is important to avoid exposure of important structures such as nerves and vessels, reduce the risk for secondary infections, prevent retractions and reduce the time for healing in the postoperative period. Data are variable regarding the risk of recurrence after surgery, according to the anatomical sites treated and the techniques used.
Weight and smoking seem to be the main risk factors for local recurrence. Axillary Hidradenitis: Risk factors for recurrence after surgical excision in patients. A retrospective study evaluated 84 patients after wide excision, with a total of procedures and mean follow-up of 36 months. Most patients reported a high level of satisfaction with the results obtained. Hidradenitis suppurativa treated with wide excision and second intention healing: a meaningful local cure rate after procedures.
This shows that treatment should be combined and there is room for clinical approach before and after surgery. Surgical treatment of hidradenitis suppurativa: an analysis of postoperative outcome, cosmetic results and quality of life in patients. Surgery during pharmacological treatment is another controversial matter, particularly considering biologic drugs. Patients who underwent surgery while on a biologic drug had better disease control than those who only had medical treatment in a study with 68 cases of moderate to severe HS.
Longitudinal observational study of hidradenitis suppurativa: impact of surgical intervention with adjunctive biologic therapy. The use of laser technologies has been appreciated for ablation and destruction of chronic lesions.
Carbon dioxide laser CO2 can be used for vaporization and excision. Nodules, abscesses and tunnels can be targeted, leaving healthy tissue in between the lesions treated. This way, the technique can spare the surrounding healthy tissue, with appropriate hemostasis and allow for speedy healing. The reports of the studies show less pain and a more comfortable postoperative period than with traditional surgery.
Hidradenitis suppurativa: Successful treatment using carbon dioxide laser excision and marsupialization. Treatment of hidradenitis suppurativa with carbon dioxide laser excision and second-intention healing.
Outcomes of treatment of nine cases of recalcitrant severe hidradenitis suppurativa with carbon dioxide laser. Recurrence rate and patient satisfaction of CO2 laser evapration of lesions in patients with hidradenitis suppurativa: a retrospective study. Intense pulsed light can provide favorable results even in Hurley II and III cases according to case series published, even though it has superficial penetration.
Treatment of hidradenitis suppurativa with intense pulsed light: a prospective study. Plast Reconstr Surg. Lasers and Intense Pulsed Light hidradenitis supurativa. Nd:YAG nm laser can be useful for hair removal, treatment of superficial lesions or associated to other modalities in moderate to severe cases.
HS is considered to be one of the diseases that impairs the quality of life of affected individuals the most. Current knowledge on its ethiopathogenesis has grown considerably and has confirmed its immune-mediated background. Treatment of the disease in early phases where there is pre-clinical inflammation without structural damage can avoid or reduce the devastating progression to fistulas and scarring, which will require surgical treatment.
Thus, early diagnosis, interventions on risk factors such as treating obesity, metabolic and hormonal disturbances and smoking cessation measures when the first signs arise are factors that can interfere with the course and severity of the disease. The inflammation phase that precedes tissue destruction represents the window of opportunity to adequately approach the disease. Treatment with antibiotics and immunosuppressants can contribute to a better systemic control of the inflammation, its repercussion in other organs and its complications.
HS patients should be screened annually due to the high prevalence of associated diseases and the higher risk of cardiovascular disease. Obesity, diabetes, hypertension, metabolic syndrome, besides inflammatory bowel disease, joint disorders, anxiety and depression, smoking and alcoholism are important conditions that should be investigated.
Clinical and surgical care should be constant since in acute phases, drainage and minor excisions can be necessary and in advanced phases, established fistulas with frequent suppuration and scarring, that are considered static lesions, require wide excisions. In this sense, multidisciplinary care should be encouraged. The use of biologics drugs was shown to be effective and safe in HS, indicated for moderate to severe cases that failed conventional treatment.
The aim of this consensus is to guide the dermatologist in the approach of the patients with HS in the Brazilian reality, and the authors are open to reevaluation and updating, besides the evaluation of its impact in the dermatology Community Figure 1. Figure 1 Recommendation for treatment of suppurative hidradenitis according to the Brazilian HS Consensus. Interventions in darker tones have higher grades of recommendation, those in red should be considered with caution.
Surgical interventions and general measures should be considered throughout patient follow-up. Open menu Brazil. Anais Brasileiros de Dermatologia. Open menu. Text EN Text English. Abstract: Hidradenitis suppurativa is a chronic immune mediated disease of universal distribution that causes great damage to the quality of life of the affected individual, whose prevalence is estimated at 0.
For didactic purposes, this consensus suggests the following description for HS lesions: Nodule: raised, palpable, edematous lesion, larger than 1 cm. Chart 1 Hurley's classification for hidradenitis suppurativa. Chart 2 General skin care measures, topical and intralesional treatments according to the level of evidence and grade of recommendation based on the literature.
Chart 3 Systemic treatments for HS according to the level of evidence and grade of recommendation based on the literature. Friedman M. Kelly G, Prens EP. Prens E, Deckers I. Fimmel S, Zouboulis CC. Boer J. Krbec AC. Alavi A, Kirsner RS. Jemec GB, Wendelboe P. Surgical treatment of hidradenitis suppurativa with gentamicin sulfate: a prospective randomized study. Boer J, Jemec GB. Scheinfeld N. Danby FW.
Danto JL. Boer J, van Gemert MJ. Boer J, Nazary M. Scheman AJ. Jemec GB. Ingram JR. Adalimumabe Humira. KG Ravensburg, Alemanha. Adalimumab for the treatment of moderate to severe Hidradenitis suppurativa: a parallel randomized trial. Ann Intern Med. Cusack C, Buckley C. Etanercept: effective in the management of hidradenitis suppurativa. An open-label phase II study of the safety and efficacy of etanercept for the therapy of hidradenitis suppurativa.
Etanercept for the treatment of hidradenitis suppurativa. Acta Derm Venereol. Experience with ustekinumab for the treatment of moderate to severe hidradenitis suppurativa. Management of recalcitrant hidradenitis suppurativa with ustekinumab. Successful long-term triple disease control by ustekinumab in a patient with Behcet's disease, psoriasis and hidradenitis suppurativa.
Ann Rheum Dis. Ustekinumab for hidradenitis suppurativa: a case report. Lixia ZE. Rompel R, Petres J. Saunte DM, Lapins J. History Received 07 July Accepted 13 Sept This is an Open Access article distributed under the terms of the Creative Commons Attribution NonCommercial License which permits unrestricted noncommercial use, distribution, and reproduction in any medium provided the original work is properly cited.
Mario Chaves: Abbvie. Approval of the final version of the manuscript; Conception and planning of the study; Elaboration and writing of the manuscript; Obtaining, analyzing and interpreting the data; Effective participation in research orientation; Critical review of the literature; Critical review of the manuscript. Approval of the final version of the manuscript; Conception and planning of the study; Elaboration and writing of the manuscript; Critical review of the literature; Critical review of the manuscript.
Approval of the final version of the manuscript; Elaboration and writing of the manuscript; Obtaining, analyzing and interpreting the data; Critical review of the literature; Critical review of the manuscript. Approval of the final version of the manuscript; Elaboration and writing of the manuscript; Critical review of the literature; Critical review of the manuscript. Figures 1 Tables 3.
Hurley staging Stage I Single or multiple abscesses, without tunnels or scarring Stage II Single or multiple isolated recurrent abscesses, with the formation of tunnels and scarring Stage III Multiple interconnected tunnels and abscesses involving at least one whole anatomic region.
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