Research letter

Topical 15% resorcinol for hidradenitis suppurativa: An uncontrolled prospective trial with clinical and ultrasonographic follow-up

Topical and intralesional (IL) treatments may be considered the first-line therapy in patients with hidradenitis suppurativa (HS); however, the evidence supporting their use is limited. The aim of our review is to evaluate the efficacy and safety profile of topical and IL treatments in patients with HS.

We designed a systematic review of the current medical literature available following the PICO(T) method. And including all types of studies (Study type [T]) of individuals with HS of any sex, age, and ethnicity (Population [P]) who received any topical or IL treatment for HS (Intervention [I]) compared to placebo, other treatments, or no treatment at all (Comparator [C]), and reported efficacy and/or safety outcomes (Outcomes [O]). Two outcomes were defined: quality of life and the no. of patients with, at least, one adverse event. The search was conducted in the Cochrane Library, MEDLINE, and EMBASE databases; study selection was performed based on pre-defined criteria. The risk of bias was determined in each study.

We obtained a total of 11,363 references, 31 of which met the inclusion criteria. These studies included 1143 patients with HS, 62% of whom were women. A total of 10, 8, 6, 2, and 5 studies, respectively, evaluated the use of photodynamic therapy (PDT), glucocorticoids, resorcinol, topical antibiotics, and other interventions. Most articles were case series (n = 25), with only five randomized clinical trials (RCTs) and one cohort study. RCTs showed improvement in disease activity with topical clindamycin and botulinum toxin (BTX) vs placebo, and PDT with methylene blue (MB) niosomal vs free MB; however, intralesional triamcinolone acetonide was not superior to placebo. The risk of bias was low in three RCTs and high in two RCTs.

The quality of evidence supporting the use of topical, or IL treatments is low. However, it supports the use of topical clindamycin, PDT, and BTX. Well-designed RCTs with standardized outcomes and homogeneous populations of patients and lesions are needed to support decision-making in the routine clinical practice.

Los tratamientos tópicos e intralesionales (IL) pueden ser considerados como tratamientos de primera línea en pacientes con hidradenitis supurativa (HS), sin embargo, la evidencia apoyando su uso es limitada. El objetivo de nuestra revisión es evaluar la eficacia y la seguridad de los tratamientos tópicos e IL en pacientes con HS.

Diseñamos una revisión sistemática de la literatura siguiendo el método PICO(T). Incluimos todo tipo de estudios (tipo de estudio [T]) que incluyeran individuos con HS de cualquier sexo, edad, y etnicidad (Población [P]), que recibieran cualquier tratamiento tópico o IL para la HS (Intervención [I]) que compararan con placebo, otros tratamientos o no tratamiento (comparador [C]) y reportaran resultados de eficacia y/o seguridad (Outcomes [O]). Dos resultados fueron definidos: calidad de vida y número de pacientes con al menos un efecto adverso. La búsqueda se llevó a cabo en las bases de datos Cochrane Library, MEDLINE y EMBASE; la selección de estudios se realizó de acuerdo con los criterios predefinidos. El riesgo de sesgo se determinó en cada estudio.

Se obtuvieron 11.363 referencias de las cuales 31 cumplieron los criterios de inclusión. Estos estudios incluyeron 1.143 pacientes con HS, 62% fueron mujeres. 10 estudios evaluaron la terapia fotodinámica (TFD), ocho glucocorticoides, seis resorcinol, dos antibióticos tópicos y cinco otras intervenciones. La mayoría de los artículos fueron series de casos (n = 25), con solo cinco ensayos clínicos aleatorizados (ECA) y un estudio de cohortes. Los ECA demostraron mejoría de la actividad de la enfermedad con clindamicina tópica y con toxina botulínica (BTX) frente a placebo y TFD con azul de metileno (AM) niosomal frente a AM libre; sin embargo, el acetónido de triamcinolona IL no fue superior al placebo. El riesgo de sesgo fue bajo en tres y alto en dos ECA.

La calidad de la evidencia que apoya el uso de tratamientos tópicos o IL es baja, pero apoya el uso de clindamicina tópica, TFD y BTX. Se requieren ECA adecuadamente diseñados con resultados estandarizados y poblaciones homogéneas de pacientes y lesiones para apoyar la toma de decisiones en la práctica clínica.

Investigation into therapeutics for hidradenitis suppurativa (HS) has increased over the past two decades. As more is understood about HS pathogenesis, the number of drug targets has steadily risen. Neutrophils as well as the complement pathway have both been shown to contribute to HS pathogenesis and have become the focus of several ongoing clinical trials. Similarly, cytokines such as IL-17, IL-12/23, and IL1-α/β are being targeted for their suspected role in HS pathogenesis. Trials are also underway for small molecule inhibitors of the JAK/STAT pathway as well as anti-hormonal therapies and CD40 blockade. Beyond pharmaceuticals, there are also several surgical, procedural, and complementary and alternative practices currently being investigated. The future of HS looks bright as investigators continue to innovate and expand on HS management.

Topical therapy is a mainstay of dermatological treatment and holds many advantages, including ease of use, relative lack of systemic side effects, and patient-directed application. In hidradenitis suppurativa (HS), topical therapeutics are often used for early-stage lesions or as adjunct therapy to systemic or surgical treatments. The four categories of disease-modifying topical therapies for sHS include antibiotics, antiseptics, keratolytics, and bathing additives (each of which will be discussed in this chapter), while topical therapies aimed at symptom-control such as analgesics and antipruritics are reviewed in Chapter 19. Unfortunately, there is a lack of robust evidence supporting the use of most topical therapies in HS. Thus, in the absence of rigorous data, the decision regarding which topical treatment to use is often made at the clinician’s discretion as well as the patient’s preference. This chapter will provide an overview of topical therapies, including their dosing schedules, mechanisms of action, contraindications, and recommendations for use to better inform these decisions.

Surgery is an essential aspect of the management of hidradenitis suppurativa, and the ability to provide this care in an office-based setting is a critical skill for dermatologist and non-dermatologist surgeons. This chapter focuses on the evidence supporting various office-based surgical interventions and provides practical guidance for how to prepare for, perform, and provide postoperative care following these procedures. Covered topics reviewed will include intralesional triamcinolone, incision and drainage, deroofing, radiotherapy, chemical peels, and neurotoxin injection.

Therapy for hidradenitis suppurativa may include both medical and procedural modalities. Pharmacologic therapies are principally focused on suppressing the inflammation of the disease. In many patients, however, persistent scars, sinus tracts, abscesses and nodules may best be managed with procedural approaches. Such procedures may be combined with pharmacologic management. Considerations may include targeted destruction, or procedures of removal. Destructive options include CO₂ laser ablation, radiation therapy, chemical peels, cryoinsufflation, and neurotoxin injections. Removal techniques have generally been limited to wide local excision with primary closure. Recently, staged carbon dioxide laser marsupialization has been demonstrated to offer the potential for complete and lasting clearing.

Hidradenitis suppurativa (HS) is a chronic, often debilitating, skin condition that historically does not respond well to treatment. Although there is no cure for HS, symptoms can be managed if the appropriate diagnosis is made. HS most commonly develops in postpubertal women and manifests as painful, deep-seated, inflamed lesions, including nodules, sinus tracts, and abscesses. HS flares are marked by increased pain and suppuration at varying intervals and can occur in women before menstruation. HS is commonly misdiagnosed; physicians might mistake a lesion for an infection, abscess, or sexually transmitted infection. Incision and drainage of these lesions often leads to recurrence. Given that management of this chronic disease is often difficult, we sought to outline current diagnosis and management strategies for HS.