Treatment
Evaluation in the ED might necessitate recommendations for inpatient admission. Dermatologic consultation can be helpful in providing ED physicians with context for interpretation of laboratory results and clinical findings. Specifically, dermatologic evaluation can help differentiate presentations consistent with a primary infection from a more common presentation of HS flaring and associated bacterial colonization. Indications for inpatient admission are severe pain; concern for systemic infection, including high fever or sepsis; and need for surgical intervention. Patients with severe disease who do not have a longitudinal care plan or who lack the ability to care for lesions at home also are candidates for inpatient admission, where they can receive more intensive nursing and wound care as well as outpatient logistical management.
Acute care should be aimed at treatments that work quickly and aggressively and have both anti-inflammatory and antimicrobial effects. Severe flares require aggressive initial treatment to ensure more long-term remission. Adalimumab, maintained at 40 mg/wk after a loading dose, is the mainstay of evidence-based treatment for moderate to severe HS in patients 12 years or older; however, this treatment might not be easy to initiate in the inpatient setting because of its cost and availability and the fact that it is not as fast acting as other therapies.26 For patients with severe disease flares, prednisone,27 infliximab,28 or cyclosporine29 can be used in combination with antimicrobial therapy in the inpatient setting to quickly control active flaring. Intravenous antimicrobial therapy might be necessary in severe disease and should include coverage of gram-positive30 and anaerobic organisms.31
Although management of acute flares is critical, especially for hospitalized patients, initiating longitudinal treatment modalities while the patient is an inpatient will help prevent future readmissions, facilitate better outcomes, and enable longer periods of disease-free progression. Specific treatments, stratified by disease severity, are listed in the Table.
Postdischarge Lifestyle Modification
All disease management should include recommendations for lifestyle modification, including counseling on terminal hair removal (ie, avoid shaving, plucking, and waxing) and recommendations for daily and weekly decolonization with chlorhexidine or other antimicrobial soap, a weekly vinegar bath, and antiperspirant use in the groin and axilla. Avoiding tight clothes and humidity might also be helpful.
Other beneficial postdischarge strategies include smoking cessation and weight loss, which often are beneficial but difficult for many patients to achieve on their own; connecting patients with a primary care provider, which can facilitate better long-term outcomes; informing patients of the natural history of the disease and providing strategies for them to implement for acute flares to help avoid readmission and ED visits; and writing a “pill-in-pocket” prescription for a course of an antibiotic that provides good staphylococcal and anaerobic coverage, which can be helpful for patients who are prone to infrequent flares.
Lastly, appropriate postdischarge maintenance therapy also can be initiated during the inpatient stay, including maintenance antibiotic therapy, spironolactone32 for female patients, and acitretin33 for comedonal-predominant patients.
Final Thoughts
Hidradenitis suppurativa is a common dermatologic condition that frequently presents in emergency and inpatient settings, given its association with painful and acutely indurated lesions that often appear concerning for infection. Elevated inflammatory markers and fever are common in HS and are not necessarily suggestive of infection. As such, while antibiotics may be part of acute management of HS, care also should address the inflammatory component of the disease. Longitudinal outpatient care coordination with a dermatologist and primary care physician is imperative for limiting ED and inpatient care utilization.