HNY Policy and Pathway Repository - York

This is a chronic inflammatory skin condition affecting apocrine gland bearing areas in the skin, usually confined to the axillae and groin but also behind the ears, submammary areas and under abdominal folds. It is characterised by recurrent boils and abscesses which form rope like scars and sinuses.

None provided

Risk factors

• Obesity and insulin resistance
• Smoking
• Inflammatory bowel disease
• Drugs- lithium, sirolimus, biologics
• Follicular occlusion triad- severe acne, dissecting cellulitis of the scalp, pilonidal sinus

Differential diagnoses

• Skin infections- boil, abcesses
• Cysts
• Cutaneous Crohn’s disease

Investigations

• Assess for cardiovascular disease/metabolic syndrome risk factors- BMI, Blood pressure, HbA1C, lipids
• Ask about any joint or GI symptoms- rarely HS can be associated with a wider body inflammatory condition where severe pyogenic arthritis, pyoderma gangrenosum and acne are present (PAPA, PAPASH, PASH syndromes)

Management

1. Reduce risk factors: Smoking cessation, weight loss both can reduce severity of HS or reverse it altogether in some cases.
2. Topical treatment: Topical erythromycin to affected areas (guidelines suggest clindamycin but this is blacklisted by CCG) and a skin cleanser eg chlorhexidine wash (hibiscrub/octenisan).
3. Dressings for leaking boils and pustules, pain management if needed.
   • These should be absorbant, low adhesive and foam dressings to reduce friction and discomfort
   • Minimal exudate- Hydrocolloid (eg duoderm extra thin) or hydrogel (actiform cool)
   • Moderate or high exudate- Kerrafoam or allevyn gentle border
   • Consider charcoal dressings if malodorous
   • Shapewear may help keep dressings in place (hidrawear is prescribable)
4. First line oral management: Oral lymecycine 408mg od or doxycycline 100mg od, or erythromycin 500mg bd if allergic/intolerant of tetracyclines for three months then review. Continue if successful, consider treatment breaks if skin clear.
5. Second line oral management: If unresponsive to tetracyclines, move to clindamycin 300mg bd for three month and review.
6. Acute treatment of large, painful lesions: These are often sterile so consider intralesional steroid (eg triamcinolone 10mg/ml) or a short course of oral steroids. If very extensive, consider infection and avoid steroids and treat with flucloxacillin 500mg qds for 7 days or clarithromycin 500mg bd for 7 days if allergic to penicillins. If not responding, consider referring for incision and drainage (though this is a temporary reprieve only).
7. Referral to secondary care: If failed at first and second line treatment, OR if failed at first line and disease very extensive, refer in to dermatology for consideration of hospital only systemic treatment (dapsone, oral retinoids, immunosuppression.

Referral guidelines

• Patient has moderate to severe hidradenitis
• Patient has failed to respond to two oral antibiotics if moderate severity or one if severe
• Immediate referral if associated with arthritis, pyoderma gangrenosum and severe acne, especially if family history present.
• Severe psychological impairment

Information to include in the referral

• Duration of condition and areas affected
• Treatments already tried
• Patient’s BMI and smoking status
• Patient current medication
• Patient’s medical and surgical history
• Photographs of the affected areas

Patient information leaftets

• Hidradenitis Suppurativa (Acne Inversa): A Complete Picture - DermNet (dermnetnz.org)
• British Association of Dermatologists (bad.org.uk)

Clinical guidelines

• Hidradenitis suppurativa (syn. acne inversa) (pcds.org.uk)
• HS-pathway-web.pdf (pcds.org.uk)
• British Association of Dermatologists guidelines for the management of hidradenitis suppurativa (acne inversa) 2018 | British Journal of Dermatology | Oxford Academic (oup.com)

Other resources

• Prescriber Information (UK) - HidraWear