|
from previous page
appropriate criteria and protocols is currently underway to help discern its place in HS treatment.
Intractable localised disease has often historically been managed surgically. It is typically considered for patients with epithelised sinus tracts and where seropurulent fluid must be drained.
Surgical treatments vary widely, from removal of the entire follicular apparatus with generous margins, to minor procedures to relieve pressure in an acute flare. In general, surgical approaches are complicated by high recurrence rates. 8-9
Quality of life HS patients grapple with debilitating pain. Regimens inclusive of steroids, tricyclic antidepressants and pregabalin are used in an attempt to ameliorate day-to-day discomfort. HS also renders patients vulnerable to feeling isolated and depressed.
The GP has an important role in identifying associated disease and referring as appropriate to other health practitioners such as a pain team or psychologist.
Various HS support groups
|
Photo courtesy Professor Rod Sinclair
exist such as the Hidradenitis Suppurativa Foundation( www. hs-foundation. org). Direct patients to groups and forums where they can discuss common problems and solutions they found helpful.
What’ s new? The use of biologic therapy should not be delayed. Two recent phase 3 double blind placebo controlled trials( PIONEER I and II) have demonstrated the efficacy of adalimumab in markedly
|
reducing the severity of disease. Marked improvements were seen in pain scores and lesion count. 22
Adalimumab is now used at the Liverpool Hospital HS clinic in moderate to severe disease immediately following failure of the second-line oral antibiotics rifampicin and clindamycin.
In HS clinics, disease activity is monitored by three-monthly histological assessment of lesions and serum inflammatory markers
|
. Ultrasound is being used for both monitoring and perioperative planning.
Summary GPs have the central and crucially important role of recognising HS and initiating treatment. Furthermore, ongoing management of the disease and its comorbidities is then essential to achieve the best outcomes possible for patients.
The treatment of HS should be initiated by GPs
|
through good hygiene and control of comorbid disease, antibacterial washes and the use of oral antibiotics such as doxycycline 100mg daily.
Refer patients to a dermatologist if basic measures and a three-month trial of tetracyclines do not result in an improvement. If antibiotics fail, use adalimumab in combination with adjuncts such as metformin, spironolactone, and corticosteroids, depending on comorbidities and symptoms.
|
A variety of surgical procedures, such as deroofing, are used in acutely painful flares. However, such procedures are associated with high rates of recurrence, and further research is required to define the role of surgical intervention.
The current delay in diagnosis for those with HS is unacceptable. The prevalence of HS is such that a greater level of knowledge in the medical community is required. Clinicians should be able to identify the key clinical features, commence initial management and refer patients promptly to a dermatologist for appropriate medical treatment.
Although the exact pathogenesis is not yet fully understood, clinicians are now coming to see HS as a systemic auto-inflammatory disease, amenable to medical treatment. ●
Dr Charlton is a dermatology resident at St George Hospital,
Sydney, NSW. Dr Rosen is a dermatologist at Liverpool Hospital, Sydney, NSW.
Associate Professor Cains( University of NSW) leads the Liverpool Hospital HS clinic.
References on request.
|