There’s been an Australian update to clinical management guidelines for this severe inflammatory skin disease.
The severe chronic skin disease hidradenitis suppurativa (HS) is linked to several other inflammatory diseases and requires aggressive treatment with multiple therapies, according to new Australasian guidelines.
“Hidradenitis suppurativa is a burdensome inflammatory skin disease with significant quality of life impact,” said the 13 Australian experts with clinical and research experience in HS.
“Overall management strategies include appropriate severity assessment of disease and comorbidities, multimodal therapy with systemic and local treatments, and evidence-based progression along the therapeutic ladder in the event of inadequate response.”
The new guidelines, which are based on a systematic review, discourage sequential monotherapy with antibiotics or single-agent therapy, and stress that moderate to severe disease needs aggressive treatment “to capture the window of opportunity”.
“Overall, the complex nature of HS requires a complex and multimodal therapeutic response with medical, physical and surgical therapies to achieve best patient outcomes,” the researchers said in the Australasian Journal of Dermatology.
HS is diagnosed using the modified Dessau criteria, which is the presence of typical lesions – nodules, abscesses, tunnels, pseudo-comedones – in typical areas – axillae, groin, sub-mammary and buttocks – found in at least two of those areas within six months.
“There are currently no histological or serological diagnostic biomarkers to differentiate HS from other conditions,” the researchers said.
“The diagnosis of HS should be made whilst considering other potential conditions which can have similar manifestations including cutaneous tuberculosis, donovanosis and folliculitis.”
HS is linked to several inflammatory co-morbidities, the researchers said, and while international guidelines recommended screening for comorbidities, the usefulness of screening hadn’t been evaluated.
But they said consensus recommendations include screening for common comorbidities including dyslipidaemia, metabolic syndrome, hypertension, diabetes mellitus, pilonidal cyst, acne vulgaris/conglobate and dissecting cellulitis of the scalp.
As for effective treatments, the researchers said the current evidence base for therapy in HS was relatively low and only a small number of agents had completed phase 3 controlled clinical trials.
“Given the relatively low level of efficacy in the context of trials, exploration into disease heterogeneity or the identification of biomarkers which may indicate the likelihood of clinical response would be helpful for practicing clinicians. “
For mild to moderate disease, therapeutic options include topical and oral antibiotics, the combined oral contraceptive pill and spironolactone. Other treatment options are laser hair removal, local surgery and intralesional botox or corticosteroids.
In moderate to severe disease, therapies include systemic biologic therapy and the management of inflammatory comorbidities such as PCOS and insulin resistance.
Flares – defined as abscess and nodule numbers 25% above baseline levels – are a common complication of HS and can occur even with systemic therapy, the researchers said.
“Proactive planning of flare management is essential. Recommended options include incision and drainage, deroofing, ILCS, oral antibiotics or oral prednisolone.”
When patients lose their response to biologic therapies – which happens to around 45% of patients – treatment options include anti-drug antibody testing, dose escalation, adjuvant therapies or switching agents.
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Any female patients wishing to have children should have their HS well managed before conception, the researchers said.
“Decision to continue monoclonal antibody therapies during the 1st and 2nd trimester are based upon a risk–benefit assessment. Certolizumab pegol does not cross the placenta and can be useful during the third trimester. Expected post-partum flares require aggressive management.”
As HS has a strong hormonal influence, the impact of pregnancy on HS varies widely, with some women experiencing remission in the first 24 weeks of pregnancy while others have significant flares, the researchers said.
HS is not a contraindication to vaginal birth or breastfeeding, the researchers added.
“Immediately post-partum, aggressive disease management should be instituted in order to prevent post-partum flares. Biologic therapy does not enter breastmilk in sufficient quantities after day three post-partum to be biologically active and the proteins are denatured in the infant gut.”
