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Study | ONLINE FIRST|

A Systematic Review of Treatments for Hidradenitis Suppurativa FREE

Pranita V. Rambhatla, MD; Henry W. Lim, MD; Iltefat Hamzavi, MD
[+] Author Affiliations

Author Affiliations: Follicular Disorders Clinic, Department of Dermatology, Henry Ford Hospital, Detroit, Michigan.


Arch Dermatol. 2012;148(4):439-446. doi:10.1001/archdermatol.2011.1950.
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Published online

Objectives To conduct a systematic review of the effectiveness of various modalities to treat hidradenitis suppurativa (HS) and to establish recommendations on its appropriate management.

Data Sources MEDLINE, Cochrane, and PubMed databases.

Study Selection English-language prospective, retrospective, and case studies describing at least 4 patients with HS.

Data Extraction Data quality and validity were addressed by multiple reviewers using independent extraction.

Data Synthesis Studies were categorized as treatments using antibiotics, biological agents, laser surgery, excisional surgery, or miscellaneous modalities. Of 62 publications included in the review, 4 studies met criteria to be assigned the highest grade for quality of evidence.

Conclusions Shown to be effective treatments for HS were a clindamycin-rifampin combination regimen, a course of infliximab, monthly Nd:YAG laser sessions, and surgical excision and primary closure with a gentamicin sulfate–collagen sponge. Most therapies used to treat HS were supported by limited or weak scientific evidence. A treatment approach is presented based on the evidence and on clinical experience at the Follicular Disorders Clinic, Department of Dermatology, Henry Ford Hospital, Detroit, Michigan. This review emphasizes the need for large randomized controlled trials to evaluate treatment options for HS.

Figures in this Article

Hidradenitis suppurativa (HS) is a chronic, inflammatory, recurrent, debilitating skin follicular disease that usually manifests after puberty with painful deep-seated inflamed lesions in the apocrine gland–bearing areas of the body, most commonly the axillary, inguinal, and anogenital regions. The prevalence of HS is estimated to be 1% among the general population.13 Despite this high prevalence, treatment options are limited, and few large-scale randomized controlled trials have explored the safety and efficacy of treatment for HS. Physicians often rely on clinical experience and trial-and-error individualized patient care. A comprehensive review of research studies on HS treatment in the last 20 years is presented, with the aim of providing treatment guidance to physicians.

DATA SEARCH

A literature search was conducted using MEDLINE, Cochrane, and PubMed databases from January 1, 1990, to November 1, 2010, to identify relevant English-language publications. Key search terms included hidradenitis suppurativa, acne inversa, or Verneuil's disease in combination with the keyword treatment. In addition, references of relevant articles and reviews were manually searched for additional sources. Bibliographies of retrieved publications were reviewed to identify sources not obtained in our search. Two of us (P.V.R. and I.H.) independently reviewed the abstracts to identify articles that met eligibility requirements. Any disagreement was resolved using arbitration by another of us (H.W.L.).

INCLUSION AND EXCLUSION CRITERIA

A study was included if it involved the treatment of HS. Studies that did not exclusively deal with the treatment for HS were excluded. However, if data among patients with HS were presented separately within the study so that the information could be abstracted independent of other data, then the study was included. Editorials and studies describing 3 or fewer patients were excluded. Review articles that mentioned treatments were excluded; however, studies cited within the articles were manually searched for possible inclusion in the review. Studies were excluded if they were not published in the English language (Figure).

Place holder to copy figure label and caption
Graphic Jump Location

Figure. Results of the systematic review.

STUDY SELECTION AND DATA EXTRACTION

Studies meeting eligibility criteria were independently abstracted and reviewed by 2 of us (P.V.R. and I.H.) using predetermined inclusion and exclusion criteria. We then independently graded the strength of the clinical recommendation based on risks, benefits, and costs. Morbidity, mortality, symptom improvement, cost reduction, and quality of life were considered in grading a recommendation.

DATA ANALYSIS

The quality of evidence was assessed based on grading recommendations published in the Archives of Dermatology4 and on evidence quality guidelines for systematic reviews. Studies were classified by treatment category (surgical, medical, or miscellaneous treatments) and listed with their grade for quality of evidence, number of patients treated, treatment intervention, and results (eTables 1, 2, 3, 4, and 5). The grades for quality of evidence were the following: A (systematic review or meta-analysis, randomized controlled trial with consistent findings, or all-or-none observational study), B (systematic review or meta-analysis, lower-quality clinical trial or study with limitations and inconsistent findings, lower-quality clinical trial, cohort study, or case-control study), and C (consensus guidelines, usual practice, expert opinion, or case series). For surgical treatments, grade B was assigned only if a study reported remission rates and focused on a particular procedure or surgical site, as these are clinically relevant variables for the clinician. Grade C was assigned to surgical studies that did not meet the requirements for grade B. A treatment approach was formulated based on results of the systematic review and on clinical experience. P values are reported when available for studies assigned grade A or grade B. For articles that did not have a consistent grading scale or were based on usual practice or expert opinion, results were reported as follows: (1) favorable (support the use of the intervention), (2) no improvement (do not support the use of the intervention), or (3) indeterminate (if the study yielded variable results). This terminology allows the presentation of results in a clinically relevant manner when study authors provided anecdotal or clinical consensus data and statistical significance was not reported.

Sixty-two publications met our inclusion criteria and are addressed in this review. Assignment of grade for quality of evidence yielded 4 studies with grade A, 16 with grade B, and 42 with grade C. Most publications that were excluded were review articles, case reports, or case series with a small sample size.

MEDICAL TREATMENTS

Twenty-five of 62 studies reviewed were identified as medical treatments for HS. They were further classified into 2 categories, antibiotics (eTable 1) or biologics (eTable 2).

Antibiotics
Biological Agents
SURGICAL TREATMENTS

Thirty of 62 studies reviewed were identified as surgical therapies for HS. These were further classified into 2 categories, laser surgery (eTable 3) or excisional surgery (eTable 4).

Laser Surgery
Excisional Surgery

Of 62 studies reviewed, 24 were in the excisional surgery category. One study was assigned grade A, 6 studies received grade B, and the others were given grade C. Because of the difficulties and ethical dilemmas encountered with designing surgical studies, most of the literature on surgical treatments of HS is centered around surgeon experience and preference among various surgical techniques. Recurrence rates and follow-up periods were included if provided by the authors; a 1-year follow-up period was considered optimal. Buimer et al35 performed the only prospective randomized controlled surgical study with grade A, in which excision was performed and followed by primary closure with or without enclosure of a resorbable gentamicin sulfate–collagen sponge, to evaluate whether the use of antibiotic sponge would reduce the incidence of postoperative infections. The use of a gentamicin-collagen sponge resulted in fewer complications and a shorter mean time until wound healing. An open study (grade B) by van der Zee et al36 explored the efficacy of a deroofing technique in which the roof of a lesion was surgically removed and the floor of the lesion was left exposed. Of 73 treated lesions, 83% showed no recurrence during a median follow-up period of 34 months, and 17% showed recurrence after a median follow-up period of 4.6 months. Postoperative bleeding in 1 patient was the only reported adverse event, and 90% of patients responded that they would recommend the procedure to other individuals with HS.

An additional 5 studies3741 (grade B) looked at the role of radical excision as a treatment option for HS. Bieniek et al41 described their experience with excision and multiple methods of wound closure over the last 10 years. They noted complete recovery in 59.7% of their patients during a 2-year follow-up period and suggested that the risk of recurrence is related more to the natural course of the disease and the width of the excision than to the closure technique. A statistically significant relationship was shown between the efficacy of a procedure and the number of body areas affected. Bohn and Svensson37 described their results among 138 patients who underwent radical excision and had follow-up times ranging from 3 months to 21 years. In 38 of 116 patients (32.8%) who completed a questionnaire, the disease recurred to some degree, and 14 of them required further operation. Rompel and Petres38 presented the results of 106 patients treated via radical wide excision, with a median postoperative follow-up time of 36 months and a 2.5% rate of recurrence within operated fields. Wound infection occurred in 3.7% of patients, and the overall complication rate was 17.8%, including suture dehiscence, postoperative bleeding, and hematoma. A retrospective study39 of 31 patients undergoing drainage procedures, limited regional surgery, and radical wide excisions showed 100% recurrence after drainage, 42.8% recurrence after limited excision, and 27% recurrence after radical excision (P < .05), with a mean follow-up period of 72 months. Wiltz et al40 performed a retrospective analysis of 43 patients with perianal HS who underwent wide local excision, or incision and drainage, or limited local excision; results showed that wide local excision was more successful in preventing recurrence of disease.

Of the remaining 17 studies (grade C), 8 studies4249 looked at surgical excision of HS, 6 studies5055 reported on the use of a various flaps during surgery, 1 study56 evaluated the use of grafts and flaps, and 2 studies57,58 documented the results of specific skin grafting techniques. These grade C studies showed variable results and could not be effectively compared owing to the inconsistent and sometimes anecdotal reporting of findings.

MISCELLANEOUS TREATMENTS

Seven of 62 studies reviewed were identified as miscellaneous treatments for HS (eTable 5). All studies received grade C for quality of evidence.

Cryotherapy

Bong et al59 reported a case series of 10 patients treated with cryotherapy; 8 patients had improvement, with a mean healing time of 25 days and no recurrence of lesions at the treated sites. Adverse events included posttreatment ulceration, infection, or both. Most patients considered cryotherapy a better treatment option than oral antibiotics, and 8 of 10 patients stated that they would consider cryotherapy again in the future.

Photodynamic Treatment

Gold et al60 reported a case study of 4 patients who underwent 3 to 4 total treatments of short-contact 5-aminolevulinic acid–photodynamic therapy using a topical 5-aminolevulinic acid, 20%, and blue light for activation, with a 3-month follow-up period. All patients had 75% to 100% clinical improvement. Strauss et al61 reported a case series of 4 patients who had a maximum of 4 treatments of 5-aminolevulinic acid–photodynamic therapy at weekly intervals. None had significant improvement in regional HS scores observed at follow-up visits.

Finasteride

Finasteride (an inhibitor of 5α-reductase type 2) was prescribed in a study62 as monotherapy (5 mg/d) in 7 patients. Six patients showed significant improvement, and 3 patients demonstrated complete healing. Two patients with follow-up periods continuing longer than 1 year reported remissions lasting 8 to 18 months.

Zinc Gluconate

In a pilot study by Brocard et al,63 a total of 22 patients with mild to moderate HS were prescribed zinc gluconate (90 mg/d). The authors reported 8 complete remissions and 14 partial remissions; gastrointestinal symptoms were the most commonly reported adverse effect.

Topical Resorcinol

Boer and Jemec64 performed an open study of 12 women with stage I or stage II HS who self-treated with topical resorcinol, 15%. Patients reported a significant decrease in pain, and the mean duration of painful abscesses was decreased.

Acitretin

A retrospective study65 was performed of 12 patients who were treated with acitretin (mean dose, 0.59 mg/kg/d) for a mean period of 10.8 months. Nine patients saw marked or complete remission after 1 course of treatment, and 3 patients showed mild to moderate improvement of their condition. Significant adverse effects were seen in all patients, including cheilitis in all patients, as well as dermatitis, hypertrichosis at the chin, sticky skin, depression, fatigue, buzzing in the ears, and photosensitivity in others. The authors reported that half of the treated group were unwilling to undergo a second course of treatment with acitretin.

The lack of randomized controlled blinded studies in treatments of HS often presents physicians with the arduous task of determining an appropriate and efficacious course of treatment for patients. A significant limitation of the review herein is in the surgical treatments section. Owing to the descriptive nature of research in surgical treatments, it is difficult to compare different grading scales and results; as such, extensive meta-analysis is difficult.

Using this comprehensive review as an evidence-based guide, we developed the following working approach for the management of HS. In our experience, Hurley clinical staging is a convenient and useful way to classify patients with HS for disease management and follow-up care. Physical examination should be performed to recognize the extent of disease and to classify Hurley stages in HS30 as follows: stage I (abscess formation [single or multiple] without sinus tracts or cicatrization), stage II (recurrent abscesses with tract formation and cicatrization [single or multiple widely separated lesions]), or stage III (diffuse or near-diffuse involvement or multiple interconnected tracts and abscesses across the entire area). The nature of this approach is progressive. Many treatments that are suggested for milder stages may also be used in patients with more diffuse involvement based on the clinician's assessment. For example, a patient with stage II HS may be prescribed topical treatments that are suggested for stage I disease in addition to an antibiotic regimen. After obtaining an extensive medical history, family history, and social history, it is appropriate to culture HS lesions for aerobic and anaerobic bacteria, as well as to obtain nasal swabs in patients refractory to treatment.66 Appropriate laboratory studies should be considered based on the patient's clinical history. In patients suspected of having hyperandrogen states (polycystic ovarian syndrome),12 it is prudent to recommend an appointment with an endocrinologist.

The influence of HS on a patient's emotional and psychological state has been shown to significantly affect quality of life and must be addressed by clinicians. Psychosocial factors often affect patient compliance and follow-up care and should be considered by physicians in the decision-making process when developing a therapeutic relationship with a patient and in establishing a workable treatment plan. Matusiak et al67 showed a statistically significant correlation between the Dermatology Life Quality Index and disease activity (R = 0.67, P < .001). This significant effect of HS on patient well-being may necessitate extensive counseling in a dermatology clinic setting and may warrant referral to a psychiatrist for additional support when deemed necessary. It is important to stress lifestyle changes, including smoking cessation.1,68,69

SUGGESTED EVIDENCE-BASED TREATMENT APPROACH
Hurley Stage I and Stage II

Topical clindamycin, 1%, lotion or solution can be used for Hurley stage I mild HS.13 It is appropriate to consider performing monthly therapy with Nd:YAG laser on the lesions.34 Carbon dioxide laser treatment is another viable option, showing some efficacy in clinical studies,2,3,3133 that should be offered to patients. Oral isotretinoin is not an effective option supported by the scientific literature and should not be initiated in this subgroup of patients.9,10 Although case series11,62 involving few patients have reported some efficacy with the use of dapsone or finasteride, no large trials support their use. Zinc gluconate (90 mg) once daily can be offered as an adjunctive treatment to patients, following appropriate counseling about potential gastrointestinal adverse effects.63 For Hurley stage II, clindamycin (300 mg) in combination with rifampin (300 mg) twice daily may be initiated for 10 weeks.5,6,8 This regimen must be started in conjunction with a comprehensive patient discussion about potential likely adverse effects, including diarrhea, which may be severe enough to lead to termination of this treatment regimen. Another efficacious option to consider is treatment with Nd:YAG laser for a minimum of 3 to 4 monthly sessions.34 If the patient is unable to tolerate these treatment regimens or if the disease continues to be refractory to treatment, focus can be shifted to the use of biological agents. Infliximab should be the first-line treatment given the favorable outcomes demonstrated by a randomized double-blind trial20 and by several case series. One small clinical trial28 and a case series27 evaluating adalimumab showed inconsistent results and provided insufficient evidence to recommend treatment for all patients with HS at this time. An ongoing open-label phase 2 study70 is under way to determine the safety and efficacy of adalimumab in moderate to severe HS. Efalizumab has been shown in a small case series29 to be an ineffective treatment modality; it was withdrawn from the US market in 2009 owing to its adverse effects. Cryotherapy59 and photodynamic therapy60,61 have shown variable results in the literature thus far; they should not be routinely recommended.

Hurley Stage III and Refractory HS

At the level of Hurley stage III HS, a trial of the aforementioned medical treatments that are used for Hurley stage I and stage II disease can be recommended before discussion of surgical options. Although the literature discusses external beam radiation treatment for refractory HS,71 no strong evidence-based data support this treatment option. In refractory HS or extremely severe cases, it is appropriate to refer patients to a plastic surgeon or reconstructive urologist (for perianal or vulvar disease) to discuss surgical options.

MULTIDISCIPLINARY APPROACH

A multidisciplinary approach using both medical and surgical treatment modalities may be required for successful treatment of HS. Surgical treatments were included in this review to present clinicians with the most comprehensive data available. We recognize that suggestions for surgical procedures and specific techniques may be beyond the scope of recommendations made by dermatologists. However, it is vital that dermatologists should know when it is appropriate to consider a surgical consultation for a patient with HS.

Although progress has been made in the last 20 years of research, most treatment options for HS are largely based on trial-and-error patient care and physician clinical experience. Until additional randomized controlled studies of existing and novel treatments are performed, the evidence-based treatment approach offered in this review will aid clinicians in managing the treatment of HS.

Correspondence: Iltefat Hamzavi, MD, Follicular Disorders Clinic, Department of Dermatology, Henry Ford Hospital, 3031 W Grand Blvd, Ste 800, Detroit, MI 48202 (Ihamzav1@hfhs.org).

Accepted for Publication: September 27, 2011.

Published Online: December 19, 2011. doi:10.1001/archdermatol.2011.1950

Author Contributions:Study concept and design: Rambhatla and Hamzavi. Acquisition of data: Rambhatla and Hamzavi. Analysis and interpretation of data: Rambhatla, Lim, and Hamzavi. Drafting of the manuscript: Rambhatla, Lim, and Hamzavi. Critical revision of the manuscript for important intellectual content: Rambhatla, Lim, and Hamzavi. Statistical analysis: Rambhatla and Hamzavi. Obtained funding: Rambhatla, Lim, and Hamzavi. Administrative, technical, and material support: Rambhatla, Lim, and Hamzavi. Study supervision: Rambhatla, Lim, and Hamzavi.

Financial Disclosure: Dr Lim serves as a consultant for La Roche-Posay/L’Oreal, Orfagen, and Dow Pharmaceutical Sciences. Dr Hamzavi serves as a consultant for Kythera; he has worked as an investigator with Abbott, Johnson & Johnson, Centocor, Dow Pharmaceutical Sciences, Cipher, and Pfizer.

Funding/Support: The Department of Dermatology at Henry Ford Hospital received a research grant on photobiology from Johnson & Johnson.

Role of the Sponsor: The sponsor had no role in the design or conduct of the study; in the collection, analysis, or interpretation of the data; or in the preparation, review, or approval of the manuscript.

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Soldin MG, Tulley P, Kaplan H, Hudson DA, Grobbelaar AO. Chronic axillary hidradenitis: the efficacy of wide excision and flap coverage.  Br J Plast Surg. 2000;53(5):434-436
PubMed   |  Link to Article
Golcman R, Golcman B, Tamura BM, Nogueira MA, Zoo CM, Germano JA. Subcutaneous fistulectomy in bridging hidradenitis suppurativa.  Dermatol Surg. 1999;25(10):795-798
PubMed   |  Link to Article
Endo Y, Tamura A, Ishikawa O, Miyachi Y. Perianal hidradenitis suppurativa: early surgical treatment gives good results in chronic or recurrent cases.  Br J Dermatol. 1998;139(5):906-910
PubMed   |  Link to Article
Rhode JM, Burke WM, Cederna PS, Haefner HK. Outcomes of surgical management of stage III vulvar hidradenitis suppurativa.  J Reprod Med. 2008;53(6):420-428
PubMed
Chuang CJ, Lee CH, Chen TM, Wang HJ, Chen SG. Use of a versatile transpositional flap in the surgical treatment of axillary hidradenitis suppurativa.  J Formos Med Assoc. 2004;103(8):644-647
PubMed
Altmann S, Fansa H, Schneider W. Axillary hidradenitis suppurativa: a further option for surgical treatment.  J Cutan Med Surg. 2004;8(1):6-10
PubMed   |  Link to Article
Geh JL, Niranjan NS. Perforator-based fasciocutaneous island flaps for the reconstruction of axillary defects following excision of hidradenitis suppurativa.  Br J Plast Surg. 2002;55(2):124-128
PubMed   |  Link to Article
Schwabegger AH, Herczeg E, Piza H. The lateral thoracic fasciocutaneous island flap for treatment of recurrent hidradenitis axillaris suppurativa and other axillary skin defects.  Br J Plast Surg. 2000;53(8):676-678
PubMed   |  Link to Article
Ortiz CL, Castillo VL, Pilarte FS, Barraguer EL. Experience using the thoracodorsal artery perforator flap in axillary hidradenitis suppurativa cases.  Aesthetic Plast Surg. 2010;34(6):785-792
Link to Article
Varkarakis G, Daniels J, Coker K, Oswald T, Akdemir O, Lineaweaver WC. Treatment of axillary hidradenitis with transposition flaps: a 6-year experience.  Ann Plast Surg. 2010;64(5):592-594
PubMed
Mandal A, Watson J. Experience with different treatment modules in hidradenitis suppuritiva: a study of 106 cases.  Surgeon. 2005;3(1):23-26
PubMed   |  Link to Article
Hynes PJ, Earley MJ, Lawlor D. Split-thickness skin grafts and negative-pressure dressings in the treatment of axillary hidradenitis suppurativa.  Br J Plast Surg. 2002;55(6):507-509
PubMed   |  Link to Article
Kuo HW, Ohara K. Surgical treatment of chronic gluteal hidradenitis suppurativa: reused skin graft technique.  Dermatol Surg. 2003;29(2):173-178
PubMed   |  Link to Article
Bong JL, Shalders K, Saihan E. Treatment of persistent painful nodules of hidradenitis suppurativa with cryotherapy.  Clin Exp Dermatol. 2003;28(3):241-244
PubMed   |  Link to Article
Gold M, Bridges TM, Bradshaw VL, Boring M. ALA-PDT and blue light therapy for hidradenitis suppurativa.  J Drugs Dermatol. 2004;3(1):(suppl)  S32-S35
PubMed
Strauss RM, Pollock B, Stables GI, Goulden V, Cunliffe WJ. Photodynamic therapy using aminolaevulinic acid does not lead to clinical improvement in hidradenitis suppurativa.  Br J Dermatol. 2005;152(4):803-804
PubMed   |  Link to Article
Joseph MA, Jayaseelan E, Ganapathi B, Stephen J. Hidradenitis suppurativa treated with finasteride.  J Dermatolog Treat. 2005;16(2):75-78
PubMed   |  Link to Article
Brocard A, Knol AC, Khammari A, Dréno B. Hidradenitis suppurativa and zinc: a new therapeutic approach: a pilot study.  Dermatology. 2007;214(4):325-327
PubMed   |  Link to Article
Boer J, Jemec GB. Resorcinol peels as a possible self-treatment of painful nodules in hidradenitis suppurativa.  Clin Exp Dermatol. 2010;35(1):36-40
PubMed   |  Link to Article
Boer J, Nazary M. Long-term results of acitretin therapy for hidradenitis suppurativa: is acne inversa also a misnomer?  Br J Dermatol. 2011;164(1):170-175
Link to Article
Jemec GB, Faber M, Gutschik E, Wendelboe P. The bacteriology of hidradenitis suppurativa.  Dermatology. 1996;193(3):203-206
PubMed   |  Link to Article
Matusiak L, Bieniek A, Szepietowski JC. Hidradenitis suppurativa markedly decreases quality of life and professional activity.  J Am Acad Dermatol. 2010;62(4):706.e1-708.e1
Link to Article
König A, Lehmann C, Rompel R, Happle R. Cigarette smoking as a triggering factor of hidradenitis suppurativa.  Dermatology. 1999;198(3):261-264
PubMed   |  Link to Article
Sartorius K, Killasli H, Heilborn J, Jemec GB, Lapins J, Emtestam L. Interobserver variability of clinical scores in hidradenitis suppurativa is low.  Br J Dermatol. 2010;162(6):1261-1268
Link to Article
 ClinicalTrials.gov. Study of adalimumab in subjects with moderate to severe chronic hidradenitis suppurativa. http://clinicaltrials.gov/ct2/show/NCT00918255. Accessed July 21, 2010
Trombetta M, Werts ED, Parda D. The role of radiotherapy in the treatment of hidradenitis suppurativa: case report and review of the literature.  Dermatol Online J. 2010;16(2):e16http://dermatology.cdlib.org/1602/letters/hs/trombetta.html. Accessed October 8, 2011
PubMed
Lasocki A, Sinclair R, Foley P, Saunders H. Hidradenitis suppurativa responding to treatment with infliximab.  Australas J Dermatol. 2010;51(3):186-190
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure. Results of the systematic review.

Tables

References

Revuz JE, Canoui-Poitrine F, Wolkenstein P,  et al.  Prevalence and factors associated with hidradenitis suppurativa: results from two case-control studies.  J Am Acad Dermatol. 2008;59(4):596-601
PubMed   |  Link to Article
Lapins J, Marcusson JA, Emtestam L. Surgical treatment of chronic hidradenitis suppurativa: CO2 laser stripping–secondary intention technique.  Br J Dermatol. 1994;131(4):551-556
PubMed   |  Link to Article
Lapins J, Sartorius K, Emtestam L. Scanner-assisted carbon dioxide laser surgery: a retrospective follow-up study of patients with hidradenitis suppurativa.  J Am Acad Dermatol. 2002;47(2):280-285
PubMed   |  Link to Article
Robinson JK, Dellavalle RP, Bigby M, Callen JP. Systematic reviews: grading recommendations and evidence quality.  Arch Dermatol. 2008;144(1):97-99
PubMed   |  Link to Article
Mendonça CO, Griffiths CE. Clindamycin and rifampicin combination therapy for hidradenitis suppurativa.  Br J Dermatol. 2006;154(5):977-978
PubMed   |  Link to Article
Gener G, Canoui-Poitrine F, Revuz JE,  et al.  Combination therapy with clindamycin and rifampicin for hidradenitis suppurativa: a series of 116 consecutive patients.  Dermatology. 2009;219(2):148-154
PubMed   |  Link to Article
Sartorius K, Lapins J, Emtestam L, Jemec GB. Suggestions for uniform outcome variables when reporting treatment effects in hidradenitis suppurativa.  Br J Dermatol. 2003;149(1):211-213
PubMed   |  Link to Article
van der Zee HH, Boer J, Prens EP, Jemec GB. The effect of combined treatment with oral clindamycin and oral rifampicin in patients with hidradenitis suppurativa.  Dermatology. 2009;219(2):143-147
PubMed   |  Link to Article
Boer J, van Gemert MJ. Long-term results of isotretinoin in the treatment of 68 patients with hidradenitis suppurativa.  J Am Acad Dermatol. 1999;40(1):73-76
PubMed   |  Link to Article
Soria A, Canoui-Poitrine F, Wolkenstein P,  et al.  Absence of efficacy of oral isotretinoin in hidradenitis suppurativa: a retrospective study based on patients' outcome assessment.  Dermatology. 2009;218(2):134-135
PubMed   |  Link to Article
Kaur MR, Lewis HM. Hidradenitis suppurativa treated with dapsone: a case series of five patients.  J Dermatolog Treat. 2006;17(4):211-213
PubMed   |  Link to Article
Kraft JN, Searles GE. Hidradenitis suppurativa in 64 female patients: retrospective study comparing oral antibiotics and antiandrogen therapy.  J Cutan Med Surg. 2007;11(4):125-131
PubMed
Jemec GB, Wendelboe P. Topical clindamycin versus systemic tetracycline in the treatment of hidradenitis suppurativa.  J Am Acad Dermatol. 1998;39(6):971-974
PubMed   |  Link to Article
Sullivan TP, Welsh E, Kerdel FA, Burdick AE, Kirsner RS. Infliximab for hidradenitis suppurativa.  Br J Dermatol. 2003;149(5):1046-1049
PubMed   |  Link to Article
Fernández-Vozmediano JM, Armario-Hita JC. Infliximab for the treatment of hidradenitis suppurativa.  Dermatology. 2007;215(1):41-44
PubMed   |  Link to Article
Fardet L, Dupuy A, Kerob D,  et al.  Infliximab for severe hidradenitis suppurativa: transient clinical efficacy in 7 consecutive patients.  J Am Acad Dermatol. 2007;56(4):624-628
PubMed   |  Link to Article
Usmani N, Clayton TH, Everett S, Goodfield MD. Variable response of hidradenitis suppurativa to infliximab in four patients.  Clin Exp Dermatol. 2007;32(2):204-205
PubMed   |  Link to Article
Mekkes JR, Bos JD. Long-term efficacy of a single course of infliximab in hidradenitis suppurativa.  Br J Dermatol. 2008;158(2):370-374
PubMed   |  Link to Article
Brunasso AM, Delfino C, Massone C. Hidradenitis suppurativa: are tumour necrosis factor-α blockers the ultimate alternative?  Br J Dermatol. 2008;159(3):761-763
PubMed   |  Link to Article
Grant A, Gonzalez T, Montgomery MO, Cardenas V, Kerdel FA. Infliximab therapy for patients with moderate to severe hidradenitis suppurativa: a randomized, double-blind, placebo-controlled crossover trial.  J Am Acad Dermatol. 2010;62(2):205-217
PubMed   |  Link to Article
Adams DR, Yankura JA, Fogelberg AC, Anderson BE. Treatment of hidradenitis suppurativa with etanercept injection.  Arch Dermatol. 2010;146(5):501-504
PubMed   |  Link to Article
Pelekanou A, Kanni T, Savva A,  et al.  Long-term efficacy of etanercept in hidradenitis suppurativa: results from an open-label phase II prospective trial.  Exp Dermatol. 2009;19(6):538-540
PubMed   |  Link to Article
Lee RA, Dommasch E, Treat J,  et al.  A prospective clinical trial of open-label etanercept for the treatment of hidradenitis suppurativa.  J Am Acad Dermatol. 2009;60(4):565-573
PubMed   |  Link to Article
Giamarellos-Bourboulis EJ, Pelekanou E, Antonopoulou A,  et al.  An open-label phase II study of the safety and efficacy of etanercept for the therapy of hidradenitis suppurativa.  Br J Dermatol. 2008;158(3):567-572
PubMed   |  Link to Article
Cusack C, Buckley C. Etanercept: effective in the management of hidradenitis suppurativa.  Br J Dermatol. 2006;154(4):726-729
PubMed
Sotiriou E, Apalla Z, Ioannidos D. Etanercept for the treatment of hidradenitis suppurativa.  Acta Derm Venereol. 2009;89(1):82-83
PubMed
Blanco R, Martínez-Taboada VM, Villa I,  et al.  Long-term successful adalimumab therapy in severe hidradenitis suppurativa.  Arch Dermatol. 2009;145(5):580-584
PubMed   |  Link to Article
Amano M, Grant A, Kerdel FA. A prospective open-label clinical trial of adalimumab for the treatment of hidradenitis suppurativa.  Int J Dermatol. 2010;49(8):950-955
PubMed   |  Link to Article
Strober BE, Kim C, Siu K. Efalizumab for the treatment of refractory hidradenitis suppurativa.  J Am Acad Dermatol. 2007;57(6):1090-1091
PubMed   |  Link to Article
Roenigk RK, Roenigk HH. Roenigk & Roenigk's Dermatologic Surgery: Principles and Practice. 2nd ed. New York, NY: M. Dekker; 1996
Finley EM, Ratz JL. Treatment of hidradenitis suppurativa with carbon dioxide laser excision and second-intention healing.  J Am Acad Dermatol. 1996;34(3):465-469
PubMed   |  Link to Article
Madan V, Hindle E, Hussain W, August PJ. Outcomes of treatment of nine cases of recalcitrant severe hidradenitis suppurativa with carbon dioxide laser.  Br J Dermatol. 2008;159(6):1309-1314
PubMed   |  Link to Article
Hazen PG, Hazen BP. Hidradenitis suppurativa: successful treatment using carbon dioxide laser excision and marsupialization.  Dermatol Surg. 2010;36(2):208-213
PubMed   |  Link to Article
Tierney E, Mahmoud BH, Hexsel C, Ozog D, Hamzavi I. Randomized control trial for the treatment of hidradenitis suppurativa with a neodymium-doped yttrium aluminium garnet laser.  Dermatol Surg. 2009;35(8):1188-1198
PubMed   |  Link to Article
Buimer MG, Ankersmit MF, Wobbes T, Klinkenbijl JH. Surgical treatment of hidradenitis suppurativa with gentamicin sulfate: a prospective randomized study.  Dermatol Surg. 2008;34(2):224-227
PubMed   |  Link to Article
van der Zee HH, Prens EP, Boer J. Deroofing: a tissue-saving surgical technique for the treatment of mild to moderate hidradenitis suppurativa lesions.  J Am Acad Dermatol. 2010;63(3):475-480
PubMed   |  Link to Article
Bohn J, Svensson H. Surgical treatment of hidradenitis suppurativa.  Scand J Plast Reconstr Surg Hand Surg. 2001;35(3):305-309
PubMed   |  Link to Article
Rompel R, Petres J. Long-term results of wide surgical excision in 106 patients with hidradenitis suppurativa.  Dermatol Surg. 2000;26(7):638-643
PubMed   |  Link to Article
Ritz JP, Runkel N, Haier J, Buhr HJ. Extent of surgery and recurrence rate of hidradenitis suppurativa.  Int J Colorectal Dis. 1998;13(4):164-168
PubMed   |  Link to Article
Wiltz O, Schoetz DJ Jr, Murray JJ, Roberts PL, Coller JA, Veidenheimer MC. Perianal hidradenitis suppurativa: the Lahey Clinic experience.  Dis Colon Rectum. 1990;33(9):731-734
PubMed   |  Link to Article
Bieniek A, Matusiak L, Okulewicz-Gojlik D, Szepietowski JC. Surgical treatment of hidradenitis suppurativa: experiences and recommendations.  Dermatol Surg. 2010;36(12):1998-2004
PubMed   |  Link to Article
Aksakal AB, Adişen E. Hidradenitis suppurativa: importance of early treatment: efficient treatment with electrosurgery.  Dermatol Surg. 2008;34(2):228-231
PubMed   |  Link to Article
Kagan RJ, Yakuboff KP, Warner P, Warden GD. Surgical treatment of hidradenitis suppurativa: a 10-year experience.  Surgery. 2005;138(4):734-741
Link to Article
Bocchini SF, Habr-Gama A, Kiss DR, Imperiale AR, Araujo SE. Gluteal and perianal hidradenitis suppurativa: surgical treatment by wide excision.  Dis Colon Rectum. 2003;46(7):944-949
PubMed   |  Link to Article
Tanaka A, Hatoko M, Tada H, Kuwahara M, Mashiba K, Yurugi S. Experience with surgical treatment of hidradenitis suppurativa.  Ann Plast Surg. 2001;47(6):636-642
PubMed   |  Link to Article
Soldin MG, Tulley P, Kaplan H, Hudson DA, Grobbelaar AO. Chronic axillary hidradenitis: the efficacy of wide excision and flap coverage.  Br J Plast Surg. 2000;53(5):434-436
PubMed   |  Link to Article
Golcman R, Golcman B, Tamura BM, Nogueira MA, Zoo CM, Germano JA. Subcutaneous fistulectomy in bridging hidradenitis suppurativa.  Dermatol Surg. 1999;25(10):795-798
PubMed   |  Link to Article
Endo Y, Tamura A, Ishikawa O, Miyachi Y. Perianal hidradenitis suppurativa: early surgical treatment gives good results in chronic or recurrent cases.  Br J Dermatol. 1998;139(5):906-910
PubMed   |  Link to Article
Rhode JM, Burke WM, Cederna PS, Haefner HK. Outcomes of surgical management of stage III vulvar hidradenitis suppurativa.  J Reprod Med. 2008;53(6):420-428
PubMed
Chuang CJ, Lee CH, Chen TM, Wang HJ, Chen SG. Use of a versatile transpositional flap in the surgical treatment of axillary hidradenitis suppurativa.  J Formos Med Assoc. 2004;103(8):644-647
PubMed
Altmann S, Fansa H, Schneider W. Axillary hidradenitis suppurativa: a further option for surgical treatment.  J Cutan Med Surg. 2004;8(1):6-10
PubMed   |  Link to Article
Geh JL, Niranjan NS. Perforator-based fasciocutaneous island flaps for the reconstruction of axillary defects following excision of hidradenitis suppurativa.  Br J Plast Surg. 2002;55(2):124-128
PubMed   |  Link to Article
Schwabegger AH, Herczeg E, Piza H. The lateral thoracic fasciocutaneous island flap for treatment of recurrent hidradenitis axillaris suppurativa and other axillary skin defects.  Br J Plast Surg. 2000;53(8):676-678
PubMed   |  Link to Article
Ortiz CL, Castillo VL, Pilarte FS, Barraguer EL. Experience using the thoracodorsal artery perforator flap in axillary hidradenitis suppurativa cases.  Aesthetic Plast Surg. 2010;34(6):785-792
Link to Article
Varkarakis G, Daniels J, Coker K, Oswald T, Akdemir O, Lineaweaver WC. Treatment of axillary hidradenitis with transposition flaps: a 6-year experience.  Ann Plast Surg. 2010;64(5):592-594
PubMed
Mandal A, Watson J. Experience with different treatment modules in hidradenitis suppuritiva: a study of 106 cases.  Surgeon. 2005;3(1):23-26
PubMed   |  Link to Article
Hynes PJ, Earley MJ, Lawlor D. Split-thickness skin grafts and negative-pressure dressings in the treatment of axillary hidradenitis suppurativa.  Br J Plast Surg. 2002;55(6):507-509
PubMed   |  Link to Article
Kuo HW, Ohara K. Surgical treatment of chronic gluteal hidradenitis suppurativa: reused skin graft technique.  Dermatol Surg. 2003;29(2):173-178
PubMed   |  Link to Article
Bong JL, Shalders K, Saihan E. Treatment of persistent painful nodules of hidradenitis suppurativa with cryotherapy.  Clin Exp Dermatol. 2003;28(3):241-244
PubMed   |  Link to Article
Gold M, Bridges TM, Bradshaw VL, Boring M. ALA-PDT and blue light therapy for hidradenitis suppurativa.  J Drugs Dermatol. 2004;3(1):(suppl)  S32-S35
PubMed
Strauss RM, Pollock B, Stables GI, Goulden V, Cunliffe WJ. Photodynamic therapy using aminolaevulinic acid does not lead to clinical improvement in hidradenitis suppurativa.  Br J Dermatol. 2005;152(4):803-804
PubMed   |  Link to Article
Joseph MA, Jayaseelan E, Ganapathi B, Stephen J. Hidradenitis suppurativa treated with finasteride.  J Dermatolog Treat. 2005;16(2):75-78
PubMed   |  Link to Article
Brocard A, Knol AC, Khammari A, Dréno B. Hidradenitis suppurativa and zinc: a new therapeutic approach: a pilot study.  Dermatology. 2007;214(4):325-327
PubMed   |  Link to Article
Boer J, Jemec GB. Resorcinol peels as a possible self-treatment of painful nodules in hidradenitis suppurativa.  Clin Exp Dermatol. 2010;35(1):36-40
PubMed   |  Link to Article
Boer J, Nazary M. Long-term results of acitretin therapy for hidradenitis suppurativa: is acne inversa also a misnomer?  Br J Dermatol. 2011;164(1):170-175
Link to Article
Jemec GB, Faber M, Gutschik E, Wendelboe P. The bacteriology of hidradenitis suppurativa.  Dermatology. 1996;193(3):203-206
PubMed   |  Link to Article
Matusiak L, Bieniek A, Szepietowski JC. Hidradenitis suppurativa markedly decreases quality of life and professional activity.  J Am Acad Dermatol. 2010;62(4):706.e1-708.e1
Link to Article
König A, Lehmann C, Rompel R, Happle R. Cigarette smoking as a triggering factor of hidradenitis suppurativa.  Dermatology. 1999;198(3):261-264
PubMed   |  Link to Article
Sartorius K, Killasli H, Heilborn J, Jemec GB, Lapins J, Emtestam L. Interobserver variability of clinical scores in hidradenitis suppurativa is low.  Br J Dermatol. 2010;162(6):1261-1268
Link to Article
 ClinicalTrials.gov. Study of adalimumab in subjects with moderate to severe chronic hidradenitis suppurativa. http://clinicaltrials.gov/ct2/show/NCT00918255. Accessed July 21, 2010
Trombetta M, Werts ED, Parda D. The role of radiotherapy in the treatment of hidradenitis suppurativa: case report and review of the literature.  Dermatol Online J. 2010;16(2):e16http://dermatology.cdlib.org/1602/letters/hs/trombetta.html. Accessed October 8, 2011
PubMed
Lasocki A, Sinclair R, Foley P, Saunders H. Hidradenitis suppurativa responding to treatment with infliximab.  Australas J Dermatol. 2010;51(3):186-190
PubMed   |  Link to Article

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Rambhatla PV, Lim HW, Hamzavi I. A systematic review of therapies for hidradenitis suppurativa. Arch Dermatol. Published online December 19, 2011. doi:10.1001/archdermatol.2011.1950.

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