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Freelance writer for Contemporary OB/GYN
The potentially disfiguring disease hidradenitis suppurativa (HS) is becoming increasingly important to gynecologists because early detection and early treatment may prevent long-term sequelae. An overview of diagnosing and treating HS was the focus of a presentation at the 2018 Annual ACOG Meeting in Austin.
Janice Bacon, MD, an ob/gyn at Women’s Health and Diagnostic Center in West Columbia, South Carolina, noted a 2015 study (Saunte, et al) in the British Journal of Dermatology that found it took on average 7 years from the onset of HS symptoms to diagnosis.
“Delayed diagnosis leaves women with risks of scarring and pain, plus disability at the site of the disease which may then require more aggressive treatments,” Dr. Bacon told Contemporary OB/GYN.
Because patients typically see their gynecologists annually and they disrobe completely for the exams, “we have the opportunity to evaluate the patient’s skin and intertriginous areas where HS generally occurs,” said Dr. Bacon. “Therefore, we may have the best chance to make an early diagnosis.”
In addition, some of the comorbidities in women with HS may be addressed by gynecologists when they see them for other gynecologic issues or during pregnancy. “Again, this is an opportunity to diagnose and treat HS early,” said Dr. Bacon.
Diagnosis is not always easy, however, because the early lesions may be mistaken for simple acne. “Both HS and acne can begin around puberty and menarche, so a physician needs to keep a close eye on the patient’s concerns about her skin,” said Dr. Bacon.
HS frequently occurs in conjunction with androgen excess disorders. “Hence, women who complain about increased facial or body hair and acne may not just have acne, but may be at risk for having HS,” said Dr. Bacon.
In patients with mild disease, there is now a focus on using topical antibiotics, specifically clindamycin gel 1%, rather than using long-term oral antibiotics as first-line therapy.
There are also some relatively inexpensive and simple adjunctive measures that may moderate HS; for example, over-the-counter chlorhexidine is particularly beneficial for women with methicillin-resistant Staphylococcus aureus. “But the scrub can also be very helpful in reducing the bacteria that are associated with the HS pilosebaceous units,” said Dr. Bacon.
Furthermore, vitamin D and metformin may be important adjunctive therapies in assisting with management of medical comorbidities in patients with HS.
Placing HS patients on anti-acne regimens, which may include an oral contraceptive regimen containing estrogen, have also been helpful in reducing androgens and treating HS lesions.
Dr. Bacon has observed a resurgence in using spironolactone (which was originally formulated to manage hypertension) to treat HS. “But, in addition, the drug is extremely antiandrogenic, both systemically and at the level of follicle itself,” she said. “Spironolactone also helps with any androgen-related acne.”
Patients who fail topical antibiotics may need to progress to periodic use of oral antibiotics. “This can be short-term therapy for flares of acne or symptoms, or up to 2 to 3 months of treatment,” said Dr. Bacon.
One of the second-line long-term oral therapies for HS is rifampin, which can be prescribed at 600 mg daily for 10 weeks. “However, this is one of the medications that is contraindicated for use with oral contraceptives,” said Dr. Bacon. Nonetheless, rifampin appears to be instrumental in reducing some of the inflammatory conditions associated with HS for patients who fail other medications.
Ob/gyns can manage some individual HS lesions in the office. “You should not simply incise the lesions. Patients may think that these lesions are hair bumps or boils and therefore may want to pop or drain the lesions themselves,” said Dr. Bacon. “This, though, may actually worsen inflammation and increase the risk of scarring.”
According to Dr. Bacon, the best in-office treatment for individual HS nodules is to apply topical anesthetic, followed by a punch biopsy to make a small entrance into the middle of the nodule. However, the nodule must be unroofed completely. A cotton swab is then used to clean out the contents. “The simplest analogy of the content is a giant whitehead,” said Dr. Bacon. “Primarily the lesions are just sebaceous material, though some infected lesions may also be present.”
Each lesion is allowed to heal secondarily. “This actually provides less scarring in the long run than the patient pinching or popping a lesion herself,” said Dr. Bacon.
For patients with severe disease in whom the above therapies fail, injectable biologics hold great promise. “I am most excited about adalimumab because it has already received FDA approval for treatment of HS,” said Dr. Bacon. “But there is also research on infliximab, which does not have FDA approval yet.”
Two lifestyle changes that gyns can encourage their HS patients to embrace are to stop smoking and lose weight
Dr. Bacon reports no relevant financial disclosures.
Saunte DM, Boer J, Stratigos A, et al. Diagnostic delay in hidradenitis suppurativa is a global problem. Br J Dermatol. 2015 Dec;173(6):1546-9. DOI:10.1111/bjd.14038.