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    Hidradenitis Suppurativa therapy options progressing

    Early recognition and treatment can prevent disease progression, improve prognosis

     

    Comorbidities add to the mix

    Medical management may also need to include care of any associated comorbidities, such as androgen excess, inflammatory bowel disease, arthritis, obesity, or insulin resistance.

    HS may also be associated with multiple other conditions. These include Crohn’s disease and arthritis, as well as the syndromes PAPA (pyogenic arthritis, pyoderma gangrenosum, acne), PASH (pyoderma gangrenosum, acne, suppurative hidradenitis), PAPASH (pyogenic arthritis, pyoderma gangrenosum, acne, suppurative hidradenitis), and SAPHO (synovitis, acne, pustulosis palmoplantaris, hyperostosis, osteitis). What role the biologics will play in the treatment of these conditions is yet uncertain.

    READ: Inflammation crucial to acne lesions, dermatologic syndromes

    “Depending on what symptoms or disease associations one may have in this context, the clinician could try using one of the biologics, which hopefully will not only treat the HS but also other associated conditions. Nevertheless, I think it is a bit early to say which biologic works best in any subset of these diseases,” Dr. Hazen says. 

    Surgical management

    In more advanced cases of hidradenitis, patients may not completely respond to medical and pharmacologic therapies alone. For such individuals, Dr. Hazen recommends adding surgical approaches to the medical therapy. Surgery may often be needed to address persistent abscesses, sinus tracts and scars.

    For less complex inflammatory lesions, debridement and/or the “unroofing” of lesions may be helpful. Other approaches may include cauterization or cryosurgery for isolated lesions. For larger or more complex lesions of hidradenitis, multiple tiers or levels of tunneling may be present and in such patients, Dr. Hazen notes that surgical removal of the entire mass is often necessary. 

    READ: Hidradenitis suppurativa therapy successful with medical, surgical approach

    “Unfortunately however, with almost all surgical treatments, recurrence rates are higher than what we would like to see,” Dr. Hazen says.

    Reasons for the high risk of recurrence are uncertain. However, in many patients, recurrence seems to be related to the persistence of the Invasive Persistent Gelatinous Mass (IPGM) within the surgically- treated areas. Dr. Hazen notes that “As you perform the surgical removal of the HS lesion, there is almost always this gelatinous material within the cavities and/or sinus tracts, and this material appears to behave almost like a growth. It seems therefore, that if there is any portion of that material remaining following the surgery, the lesion is at risk of recurrence.” Whether the stem cells identified within the gelatinous mass are responsible for the recurrence, as well as for the other features of HS, is uncertain.

    According to Dr. Hazen, data from the plastic surgery literature also suggests that surgical closure of the wound after removal of HS, with either primary closure, flaps, or skin grafts, also appears to increase the risk of local recurrence. Whether these recurrences are a result of persistent IPGM or related to trauma to the follicle from the closure is uncertain.

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