Chronic Pain Management
Although HS is not a curable disease, there are treatments available to minimize symptoms. Long-term management of HS is essential to minimize the effects of chronic pain and physical scarring associated with inflammation.31 In one study from the French Society of Dermatology, pain reported by patients with HS was directly associated with severity and duration of disease, emotional symptoms, and reduced functionality.51 For these reasons, many treatments for HS target reducing clinical severity and achieving remission, often defined as more than 6 months without any recurrence of lesions.52 In addition to lifestyle management, therapies available to manage HS include topical and systemic medications as well as procedures such as surgical excision.36,43,52,53
Lifestyle Modifications
Regardless of the severity of HS, all patients may benefit from basic education on the pathogenesis of the disease.36 The associations with smoking and obesity have been well documented, and treatment of these comorbid conditions is indicated.36,43,52 For example, in relation to obesity, the use of metformin is very well tolerated and seems to positively impact HS symptoms.43 Several studies have suggested that weight reduction lowers disease severity.28-30 Patients should be counseled on the importance of smoking cessation and weight loss.
Finally, the emotional impact of HS is not to be discounted, both the physical and social discomfort as well as the chronicity of the disease and frustration with treatment.51 Chronic pain has been associated with increased rates of depression, and 43% of patients with HS specifically have been diagnosed with major depressive disorder.7 For these reasons, clinician guidance, social support, and websites can improve patient understanding of the disease, adherence to treatment, and comorbid anxiety and depression.52
Topical Therapy
Topical therapy generally is limited to mild disease and is geared at decreasing inflammation or superimposed infection.36,52 Some of the earliest therapies used were topical antibiotics.43 Topical clindamycin has been shown to be as effective as oral tetracyclines in reducing the number of abscesses, but neither treatment substantially reduces pain associated with smaller nodules.54 Intralesional corticosteroids such as triamcinolone acetonide have been shown to decrease both patient-reported pain and physician-assessed severity within 1 to 7 days.42 Routine injection, however, is not a feasible means of long-term treatment both because of inconvenience and the potential adverse effects of corticosteroids.36,52 Both topical clindamycin and intralesional steroids are helpful in reducing inflammation prior to planned surgical intervention.36,52,53
Newer topical therapies include resorcinol peels and combination antimicrobials, such as 2% triclosan and oral zinc gluconate.52,53 Data surrounding the use of resorcinol in mild to moderate HS are promising and have shown decreased severity of both new and long-standing nodules. Fifteen-percent resorcinol peels are helpful tools that allow for self-administration by patients during exacerbations to decrease pain and flare duration.55,56 In a 2016 clinical trial, a combination of oral zinc gluconate with topical triclosan was shown to reduce flare-ups and nodules in mild HS.57 Oral zinc alone may have anti-inflammatory properties and generally is well tolerated.43,53 Topical therapies have a role in reducing HS-associated pain but often are limited to milder disease.