The PIONEER I trial is testing adalimumab, a biologic agent, for hidradenitis suppuritiva.  The findings have been promising and will be published.  I have provided a link for the clinical trial.  Other clinical trials with biologics have shown promising results as well.  A wonderful review article by Danish researchers outlines this fact.  Please let me know if you have other questions.

Srikanta Banerjee, MD, MPH

University of Roehampton Faculty

Dear All,

I see such patients regularly, and indeed, some suffer extensive disease.I diagree with Dr Broxmeyer that antibiotics are first line treatment, as the infectious part is just due due surinfection and not the primary cause. Extensive android development of the sebaceous glands is certainly involved, as you never see the diesese in women without android hallmarks. I Always change their hormonal milieu to a cyproterone dominated milieu. Also ygienic measures, reduction of sugars and animal fat (reducing obesity, often related) is a collateral measure. If a lesion Always re-appears on the same site, it means the glands are destroyed and hide bacteria. This I treat with proper and deep surgical removal. But again, only on the condition it is repeatedly recurent on the same spot.

Many thanks to Lawrence and Gilbert for sharing your insight and experience.  Your comments and suggestions are much appreciated. 

Best regards

Sayed

Sayed S Bukhari MD, FRCPath 

consultant in infection

Midlands, UK

I would suggest, although it sounds somewhat impudent, that a reading of the recent review in Best Practices will bring several areas up to date for you. See the Open Access article at http://www.bestpracticeobgyn.com/article/S1521-6934%2814%2900136-9/abstract

Also, if you have UpToDate.com available, take a look at that as well.

Current Treatment? Which and when?

Lange's Current Medical Diagnosis & Treatment 2014 or

Conn's Current Therapy 2014 or

Lange's Current Diagnosis and Treatment Surgery 2014 or

another title / publisher?  ??

Who is the author?

Where might we read your writings on this particular disease? PubMed offers some hypotheses, I note, and I gather fecal microbiome transplants might interest you with regard to the menegamant of that colitis.

As to the quote provided, I couldn't agree more - who wrote that?

Adalimumab

Dear Dr Bukhary

In our center, we are following 20 to 30 patients corresponding to your description (Hurley stage 3 patients). These patients are often not candidates for surgery because of the size and number of lesions. Moreover, surgery without preliminary antibiotics is often associated with relapses at the border which is both distressing for patients and physicians. You are right, oral antibiotic treatments do not work in this severe form of the disease, probably because of inadequate antimicrobial spectrum or poor diffusion within lesions.

Our protocol (compassionate treatment) is to treat these patients with  prolonged courses of broad spectrum antibiotics in order to prepare surgery. Ertapenem (1g daily) is usually given for 6 weeks after verifying the absence of Pseudomonas areuginosa using a peripherally inserted catheter. This treatment significantly decreases the clinical severity of patients (50% of initial Sartorius score, personal data, paper recently refused by the JAAD editor because our results were not interesting enough to be reported...).

New antibiotic courses are required (at least for 6 months)  to obtain clinical remissions of lesions or significant improvement allowing surgery, and all lesion areas must be excized one by one. Indeed, relapses are the rule if surgery is not performed and the benefit of antibiotics is lost. Moreover,lesions can become resistant to previously efficient treatments.

Best regards

Olivier Join-Lambert

Dear Dr. Broxmeyer

In an earlier post you wrote "as a Surgeon and one who has written up this particular disease". So I wondered where that might have been written.

Re: your statement "the quote says that Clindamycin is a good idea." - actually it refers to the limited effect of the drug on sinuses, one of the reasons (the other being the C. diff problem) that I have never recommended it for my HS patients.

One of the problems with writing reviews or others' work is that one often needs to rely on 'Evidence Based Medicine' - and that limits what I am permitted to say. Frankly, I dislike being pushed to practice by looking only in the review mirror. It is a poor way to drive and a dangerous way to practice - better to look into the future for better ways.

Fecal microbiome transplants are one of those ways to clean up the errors generated by 'rear-view' medicine (and surgery).

FERNANDES NC . Hidradenitis suppurativa : retrospective study of 20 cases .An Bras Dermatol 2013 ;88 (3):486-7 .

In this study ,wide surgical excision has offered good results in severe cases of the disease ; although relapses have occurred at variable intervals in the follow-up period all patients experienced a quality  improvement of life .Two weeks before the surgery , oral prednisone--40mg /day--has reduced  the inflammation and has allowed a better handling of lesions.; this dose  does not demand slow withdrawal . 

.

Excision of affected area with skin grafting. 

Dear Bukhari 

Hidradenitis suppurativa (H S) is an annoying chronic condition characterized by swollen, painful and inflamed lesions in the axillae, groin, and other parts of the body that contain apocrine glands. The disease was originally attributed to a chronic acneiform infection of the apocrine glands but more recently it was documented to be due to a folliculitis. The hallmark of the disease is sinus tracts and draining fistulas in the skin. We reported here a rare case of H S in a 26 years old Sudanese female, who, presented with insidious onset and progressive course of nodulo-pustular lesions that discharged foul pus of 2 month duration. The lesions involved the chin, cheeks and the forehead. The diagnosis was confirmed by histopathology. By immunostaining the lesions were positive for Helicobacter pylori antigen. A stool examination was positive for H. pylori infection. The patient responded well to ant- H. pylori therapy and the lesions regressed.

Adil H. H. Bashir1,2,*, Waleed M Elamin3, Lamyaa A El Hassan4, Abdel Khalig Muddathir2,3, Khalid O. Alfarouk1,2, Ahmed M El Hassan1. Hidradenitis Suppurativa (HS), in Association with Helicobacter Pylori, in a Female Sudanese Patient: Case Report. American Journal of Dermatology and Venereology 2014, 3(1): 1-4.

It is quite impossible to eradicate the aerobic and anaerobic bacteria mostly cultured from chronic lesions by employing even a long course of systemic antibiotics. Besides , poor tolerance and side effects will ruin any therapeutic scheme. In the pre operative period the antibiotics are useful if an increasing purulent discharge and systemic signs occur ( fever . pain. leucocytosis ) .