Combined medical and surgical therapy for hidradenitis suppurativa

In this issue of the JAAD, Aarts et al compare the clinical effectiveness of adalimumab combined with surgery versus adalimumab monotherapy in patients with moderate-to-severe hidradenitis suppurativa and report better outcomes with combination therapy. In previous letters from the editor, I have discussed evolving medical interventions for hidradenitis suppurativa and noted that for severe disease, surgical intervention still reigns supreme.1Elston D.M. Hidradenitis suppurativa: new drugs, old challenges.J Am Acad Dermatol. 2020; 83: 733-734Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar,2Elston D.M. Opportunities for better outcomes in patients with hidradenitis suppurativa.J Am Acad Dermatol. 2021; 84: 1247-1248Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Wide excision of severely affected tissues and limited excision of localized disease can result in dramatic improvements in the quality of life for patients with this devastating disease.3Prens L.M. Huizinga J. Janse I.C. Horváth B. Surgical outcomes and the impact of major surgery on quality of life, activity impairment and sexual health in hidradenitis suppurativa patients: a prospective single centre study.J Eur Acad Dermatol Venereol. 2019; 33: 1941-1946Crossref PubMed Scopus (37) Google Scholar,4Kohorst J.J. Baum C.L. Otley C.C. et al.Patient satisfaction and quality of life following surgery for hidradenitis suppurativa.Dermatol Surg. 2017; 43: 125-133Crossref PubMed Scopus (27) Google Scholar Surgery is often combined with medical therapy and more recently with photodynamic therapy.5Li Y. Li T. Chen L. Zhang L. Patient satisfaction and quality of life after surgery combined with 5-aminolevulinic acid-based photodynamic therapy for hidradenitis suppurativa.J Am Acad Dermatol. 2021; 85: 1016-1017Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Patients with large pelvic, perianal, or subcutaneous abscesses require thorough drainage and may benefit from antibiotic therapy. Metronidazole offers the most reliable coverage for “below the diaphragm” anaerobes and is often combined with rifampin, and more recently with moxifloxacin, transitioning to cotrimoxazole maintenance.6Delage M. Jais J.P. Lam T. et al.Rifampin-moxifloxacin-metronidazole combination therapy for severe Hurley stage 1 hidradenitis suppurativa: prospective short-term trial and 1-year follow-up in 28 consecutive patients.J Am Acad Dermatol. 2023; 88: 94-100Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Ertepenem has also shown real promise. The study by Aarts et al in this issue reminds us that despite all of the recent advances in medical therapy, surgery still has an important place in the management of patients with moderate-to-severe disease. If you are not already proficient in unroofing and curettage of interconnecting sinus tracts, your patients will benefit when you acquire the skill. It is not difficult and these patients are already adept at dressing complex exudative wounds. Postoperative care is often less than what they are used to. A small loop or chalazion curette makes a handy probe to determine the direction of interconnecting sinus tracts. Insert the probe, unroof each tract, and curette to normal tissue. Do not stop until all interconnecting tunnels have been unroofed. The closure is possible for deep areas, but most will heal well by secondary intention. Most patients will require medical therapy as well as surgery. Emerging data support topical antiseptic washes (eg, chlorhexidine), topical clindamycin, oral metformin and spironolactone, psoriasis biologics, anakinra, and canakinumab. We are fortunate that a number of pharmaceutical companies are pursuing labeled indications for the treatment of this challenging condition. None disclosed. Adalimumab in conjunction with surgery compared with adalimumab monotherapy for hidradenitis suppurativa: A Randomized Controlled Trial in a real-world settingJournal of the American Academy of DermatologyVol. 89Issue 4PreviewAdalimumab, the only biologic registered for hidradenitis suppurativa, shows clinical response in up to 60% of patients, leaving many patients in need for other treatment options such as surgery. Full-Text PDF Open Access