Title: GZ / The Grenz Zone Season 3 / Ep 35
Tags: GZ DermnetNZ

Q: Hidradenitis suppuritiva (aka [...]) is a chronic, inflammatory skin disorder beginning after puberty with painful papules, nodules, and draining abscess-like lesions that may progress to sinus tracts and disfiguring scarring
A: acne inversa
Back Extra: Most commonly in armpits, inframammary areas, and groin

Q: The [...] staging system is the most commonly used staging system for hidradenitis suppuritiva
A: Hurley
Back Extra: Stage 1: isolated papules, nodules, and abscesses of the intertriginous areas with minimal scarring
Stage 2: similar lesions to stage 1 with a limited number of scarring lesions and sinuses that are NOT interconnected
Stage 3: similar lesions to previous stages with diffuse and interconnected scarring sinuses

Q: A patient with HS has papules, nodules, and abscesses of the intertriginous areas with minimal scarring
This would fall under Hurley stage [...]
A: I
Back Extra: Stage 1: isolated papules, nodules, and abscesses of the intertriginous areas with minimal scarring
Stage 2: similar lesions to stage 1 with a limited number of scarring lesions and sinuses that are NOT interconnected
Stage 3: similar lesions to previous stages with diffuse and interconnected scarring sinuses

Q: A patient with HS has papules, nodules, and abscesses of the intertriginous areas with a limited number of scarring lesions and sinuses that are NOT interconnected
This would fall under Hurley stage [...]
A: II
Back Extra: Stage 1: isolated papules, nodules, and abscesses of the intertriginous areas with minimal scarring
Stage 2: similar lesions to stage 1 with a limited number of scarring lesions and sinuses that are NOT interconnected
Stage 3: similar lesions to previous stages with diffuse and interconnected scarring sinuses

Q: A patient with HS has papules, nodules, and abscesses of the intertriginous areas with diffuse and interconnected scarring sinuses
This would fall under Hurley stage [...]
A: III
Back Extra: Stage 1: isolated papules, nodules, and abscesses of the intertriginous areas with minimal scarring
Stage 2: similar lesions to stage 1 with a limited number of scarring lesions and sinuses that are NOT interconnected
Stage 3: similar lesions to previous stages with diffuse and interconnected scarring sinuses

Q: Double ended-comedones are a key diagnostic clue in [...]
A: hidradenitis suppuritiva
Back Extra: Along with cycles of flares and remissions

The comorbidities of hidradenitis suppuritiva can be remembered with the mnemonic ADIOS PAPI
o A- Arthritis
o D- Diabetes
o I- Inflammatory bowel disease
o O- Obesity
o S- Smoking or squamous cell carcinoma
o P- Polycystic ovarian syndrome (PCOS)
o A- Anxiety or depression, acne tetrad
o P- Pyoderma gangrenosum
o I- Insulin resistance or metabolic syndrome
Back Extra: o A- Arthritis (up to 50% of HS patients)
o D- Diabetes (up to 30% of HS patients, 3x increased risk)
o I- Inflammatory bowel disease (2x increased risk for Crohn’s, 1.5x increased risk for UC)
o O- Obesity (approximately 75% of HS patients)
o S- Smoking (approximately 75% of HS patients) or squamous cell carcinoma
o P- PCOS (up to 10% of HS patients, 3x increased risk)
o A- Anxiety or depression, acne tetrad
o P- Pyoderma gangrenosum
o I- Insulin resistance or metabolic syndrome

What four conditions make up the follicular occlusion tetrad?
Acne conglobata
Dissecting cellulitis of the scalp
Hidradenitis suppuritiva
Pilonidal cysts
Back Extra: Patients don't often have all four, but they may have 2-3 of these conditions in lifetime

Q: Vitamin [...] and [...] are two supplements that may help patients with HS
A: D; zinc gluconate
Back Extra: There are 2 types of zinc, zinc sulfate and zinc gluconate
Remember, zinc gluconate is the good one to buy

Q: In addition on counseling patients to lose weight, stop smoking, and avoid tight fitting clothing, patients with HS can also benefit by eliminating ingestion of [found in beer, breads, and other supplements]
A: brewer’s yeast

Q: [...] is the first and only FDA approved treatment for hidradenitis suppuritiva
A: Adalimumab
Back Extra: However, many other therapies are commonly used

Q: The recurrence rate for hidradenitis suppuritiva lesions following incision and drainage is [...]
A: 100%
Back Extra: Thus it is only recommended for acute abscesses for discomfort relief
Vs deroofing, which has recurrence rates of 25% or less

The 5 main methods to manage hidradenitis suppuritiva are
1) Avoidance of triggers
2) Washes and topical treatments
3) Systemic oral treatments
4) Biologics
5) Surgery
Back Extra: Triggers - Smoking cessation and weight loss may induce remission in applicable patients
Antibacterial washes (benzoyl peroxide or chlorhexidine (Hibiclens), zinc pyrithione) o Topical antibiotic gels (clindamycin gel)
Systemic oral agents - Antibiotics, retinoids, hormonal therapies, and immunomodulators
Biologics - May consider TNF-α inhibitor, IL 12/23 inhibitor, or IL-1 inhibitor
Surgery- incision and drainage, deroofing, excision, CO2 laser excision, marsupialization, cryotherapy

Hidradenitis suppuritiva is often managed with systemic oral agents, which can can come from a variety of classes
Antibiotics
Retinoids
Hormonal therapies
Immunomodulators
Back Extra: Oral antibiotics - Doxycycline 100 mg BID, Clindamycin 300 mg BID with rifampin 300 mg BID; 2nd to 3rd line: Rifampin 300 mg BID with moxifloxacin 400 mg daily and metronidazole 500 mg BID to TID; Less commonly: Dapsone 50- 200 mg daily, other oral antibiotics such as Bactrim; Rescue treatment or bridge to surgery: IV ertapenem at 1 g daily
Retinoids - Isotretinoin 0.5 to 1 mg/kg/day (this regimen may be especially beneficial in HS patients with bad acne), Acitretin 0.5 mg/kg/day
Hormonal therapies - Spironolactone 100-150 mg daily; Metformin 500 mg BID or TID (beneficial in HS patients with PCOS); oral contraceptives with ethinyl estradiol (progestin-only minipill can worsen HS)
Immunomodulators - Prednisone 0.5 to 1 mg/kg/day tapered over days to weeks for flares and/or to bridge to other treatments; other immunomodulators include cyclosporine, colchicine with minocycline, and apremilast (Otezla)