Presentation
Hidradenitis Suppurativa (HS) presents as lumps, boils or tunnels of flexural skin. It is most commonly seen in the axillae, groins and under the breasts, but can also be found on the buttocks, natal cleft, apron fold and abdomen.
Consider diagnosis if there are typical lesions in a typical distribution and two or more episodes of lesions occurring over 6 months. Delayed diagnosis is common. If any tunnels are present then this indicates moderate to severe disease and requires secondary care review.
It is strongly associated with obesity and smoking and addressing these risk factors is an important part of management.
HS lesions:
Nodules
- Inflamed lumps which can be painful
Abscesses
- Larger, more swollen and fluctuant than nodules
- Very painful
- Will often burst discharging blood and pus
Tunnels/sinus tracts
- Blind ended openings to the skins surface
- Discharge pus
- Tunnels represent scarring and are irreversible
- Scarring causes sulci giving cerebriform or rope-like appearances
Comedones
- Less common that other lesions and cause less morbidity
- Can respond to acne type topical treatments e.g. retinoids
Treatment/therapy
Mild: Intermittent small numbers of inflammatory nodules and/or abscesses. Minimal scarring and no tunnels
Treatment:
- Doxycycline 100mg od for 3 months (or Lymecycline 408mg od if intolerant of doxycycline)
- Topical 1% clindamycin lotion
- Antiseptic wash (e.g. Chlorhexidine)
- Assess for metabolic syndrome
- Assess pain, itch and wound management requirements
- Assess mood
Lifestyle factors: smoking cessation, weight loss if overweight
Provide BAD patient information leaflet
Moderate to Severe: More frequent or constant nodules and/ or abscesses with scarring +/- tunnels
Refer to Dermatology
Treatment whilst awaiting secondary care review:
- Doxycycline 100mg od for 3 months (or Lymecycline 408mg od if intolerant of doxycycline)
- Topical 1% clindamycin lotion
- Antiseptic wash (e.g. Chlorhexidine)
- Consider rifampicin 300mg bd and clindamycin 300mg bd for 3 months if doxycycline ineffective
- Consider off label use of metformin MR up-titrate to 1.5g daily
- Consider off label use of spironolactone 50-100mg od for females if having cyclical flares
- Assess for metabolic syndrome
- Assess pain, itch and wound management requirements
- Assess mood
Lifestyle factors: smoking cessation, weight loss if overweight
Provide BAD patient information leaflet
Treatment of acute flares (e.g. acutely inflamed abscess) regardless of disease severity
- Consider co-amoxyclav 625mg tid for 7 days
- If penicillin allergic consider clarithromycin or co-trimoxazole
Referral management
Manage mild disease in primary care initially and consider referral if poor response to treatment.
For moderate to severe disease, please refer to Dermatology and commence initial management as outlined
Dermatology
