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November 28, 2017

Hidradenitis Suppurativa: Advances in Diagnosis and Treatment

Author Affiliations
  • 1Department of Dermatology, Zealand University Hospital, Roskilde, Denmark; Health Sciences Faculty, University of Copenhagen, Denmark
JAMA. 2017;318(20):2019-2032. doi:10.1001/jama.2017.16691
Key Points

Question  How has the diagnosis and treatment of hidradenitis suppurativa (HS) recently changed?

Findings  Weight reduction is important for obese patients. Drug treatment usually begins with systemic antibiotics although this approach is based on clinical experience rather than through randomized clinical trials. Adalimumab is the first drug specifically approved by the US Food and Drug Administration for the treatment of HS, but other biologics are useful. Newer surgical approaches include skin tissue–sparing excision with electrosurgical peeling (STEEP) and carbon dioxide laser evaporation.

Meaning  Hidradenitis suppurativa has a new array of medical and surgical treatments to facilitate its treatment.


Importance  Hidradenitis suppurativa (HS) is relatively common, with the prevalence of 0.05% to 4.10%, yet many patients receive inadequate treatment.

Objective  To review the diagnosis, epidemiology, and treatment of HS with an emphasis on advances in the last 5 years.

Evidence Review  A literature search was conducted using PubMed, MEDLINE (Medical Subject Headings [MeSH]), and EMBASE to include recently published treatment studies (searched from September 1, 2011, to May 1, 2017). Reviews, guidelines, conference abstracts, and studies with less than 10 patients were excluded. Furthermore, internet searches for guidelines on hidradenitis suppurativa using Baidu, Bing, Google, and Qwant browsers were performed.

Findings  The diagnosis of HS is made by lesion morphology (nodules, abscesses, tunnels, and scars), location (axillae, inframammary folds, groin, perigenital, or perineal), and lesion progression (2 recurrences within 6 months or chronic or persistent lesions for ≥3 months). HS is more common than was previously thought based on epidemiological analysis (0.05%-4.10%). Disability from HS can be significant. Patients with HS may have significant comorbidities (eg, obesity, metabolic syndrome, diabetes, and arthritis) and increased all-cause mortality (incidence rate ratio, 1.35 [95% CI, 1.15-1.59]). Antibiotic treatment with combinations of clindamycin and rifampicin, or ertapenem followed by combination rifampicin, moxifloxacin, and metronidazole for 6 months is effective. Adalimumab is effective in a significant proportion of patients and treatment with IL-1 and IL-12 receptor subunit beta 1 (Rb1) antibodies may also be useful. Tissue-sparing surgical techniques and carbon dioxide laser treatments also are available, but the evidence on clinical outcomes with these approaches is limited.

Conclusions and Relevance  Hidradenitis suppurativa is more common than previously thought and may be treated by an array of pharmacological and surgical techniques. Hidradenitis suppurativa should be considered in the differential diagnosis of nodular lesions or sinus tracts present in the axillae, groin, perineal, and mammillary fold regions.

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