Biological and surgical treatment of severe hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic, purulent, recurrent, devastating skin disease that affects approximately 1% of the general population. HS typically affects the flexural areas of the body such as the axilla, groin, and perianal area. HS is generally perceived as a difficult skin disease to treat. In this thesis we focus mainly on the treatment of severely affected patients, based on biological (TNF-α inhibitors) as well as a surgical approaches. A minor part of this thesis covers the disease’s genetic background and provides new insights into the clinical description of HS.
If conventional treatment options fail, the (off-label) use of TNF-α inhibitors to reduce inflammation can be a useful supplement for the treatment of recurrent severe HS. Infliximab should be preferred based on the most encouraging results regarding efficacy and expenses, and adalimumab seems promising when administered in higher doses. Though, a new observation is that some HS patients develop arthritis after treatment with infliximab.
Anti-inflammatory agents reduce inflammation, pain, swelling, and purulent discharge, but epithelialized cavities and fistulas will not disappear. When residual lesions are neglected, disease may spread from these sinuses or fistulas into the surrounded healthy cured tissue. To achieve long-term improvement, additional surgical interventions are necessary to remove all remaining lesions that have not responded to medical treatment. Limited surgery can be performed on an outpatient basis under local anesthesia, and is generally well tolerated. A combined approach is recommended for patients with severe HS consisting of antibiotics, TNF-α inhibitors and surgery.