Hidradenitis suppurativa (HS)
นิยาม
Hidradenitis suppurativa (HS) หรือ acne
inversa เป็น chronic inflammatory follicular
occlusive disease ของ folliculopilosebaceous unit
(FPSU) ไม่ใช่โรคของ apocrine gland โดยตรง
ลักษณะเด่นคือ recurrent painful nodules, abscesses,
skin tunnels (sinus tracts), comedones และ scarring ในบริเวณ intertriginous skin
Epidemiology
- Prevalence
~ <1–4%
- อายุเริ่มพบบ่อย: วัยรุ่น–อายุ <40 ปี (peak 18–29 ปี)
- เพศ: หญิง > ชายในยุโรป/อเมริกา (≈2–4:1)
แต่บางประเทศเอเชียพบชายมากกว่า - Pediatric
HS พบได้น้อย (<0.1%) มักเริ่มหลังอายุ
10 ปี
- Risk
modifiers: genetics, socioeconomic status, smoking, obesity
Pathogenesis (Key concepts)
HS เป็นโรค follicle-centered
inflammatory disease
กลไกหลัก
1.
Follicular hyperkeratosis → follicular occlusion
2.
Follicular dilation → rupture
3.
Release of keratin, sebum, bacteria → innate + adaptive immune
activation
4.
Chronic inflammation → granulomatous inflammation, skin tunnel
formation, fibrosis
Immune dysregulation
- ↑ TNF-α, IL-1β, IL-17, IL-18
- Complement
activation (C3a, C5a)
- Neutrophilic
dermatosis, NETs
- Response
to anti-TNF therapy supports immune role
Associated / Exacerbating Factors
- Genetics:
~40% มี first-degree relative
Gamma-secretase / Notch pathway mutations (NCSTN, PSEN1, PSENEN) พบได้น้อย - Mechanical
stress: friction, pressure (intertriginous, beltline)
- Obesity:
severity correlates with BMI
- Smoking:
strong association (↑
severity)
- Hormones:
perimenstrual flare, response to antiandrogen
- Bacteria:
secondary role (biofilm hypothesis)
- Drugs:
androgenic progestins, lithium; paradoxical HS with biologics
Clinical Manifestations
Distribution
- Axilla
(most common), groin, perineal/perianal, inframammary
- Buttocks,
inner thighs, pubic/genital area
- Non-intertriginous
areas with friction possible
Primary lesions
- Deep-seated
painful inflammatory nodules
- Progress
→ abscess → spontaneous drainage
- Skin
tunnels with malodorous discharge
- Comedones
(double/multi-headed “tombstone comedones”)
- Scarring:
fibrotic rope-like bands, contractures, lymphedema
Systemic / QoL impact
- Severe
pain, fatigue, odor, discharge
- ↑ depression, anxiety,
suicide risk
- Diagnostic
delay common (เฉลี่ย ~7 ปี)
Clinical Staging (Hurley)
|
Stage |
Description |
|
I |
Abscess(es) ไม่มี skin
tunnel หรือ scarring |
|
II |
Recurrent abscesses + skin
tunnels + scarring (localized) |
|
III |
Diffuse involvement, multiple
interconnected tunnels |
Overall stage = worst affected area
Associated Disorders
- Metabolic
syndrome: DM, obesity, dyslipidemia, HTN, ASCVD
- Inflammatory
bowel disease (especially Crohn disease)
- Acne
vulgaris
- Follicular
occlusion tetrad
(HS, acne conglobata, dissecting cellulitis scalp, pilonidal disease) - Autoinflammatory
syndromes: PASH, PAPASH
- Psychiatric
disorders
- Adverse
pregnancy outcomes
- Increased
mortality (mainly cardiovascular, cancer)
Histopathology (supportive, not diagnostic)
- Early:
follicular hyperkeratosis, plugging, perifolliculitis
- Late:
mixed dermal/subcutaneous inflammation, tunnels lined by squamous
epithelium, fibrosis, granulomas
Diagnosis
Clinical diagnosis based on:
1.
Typical lesions
2.
Typical locations
3.
Chronicity/recurrence
Investigations
- Biopsy:
ไม่จำเป็น ยกเว้น exclude DDx หรือสงสัย SCC
- Culture:
ไม่ routine (ทำเมื่อสงสัย infection
แท้)
- Imaging:
- US:
identify subclinical skin tunnels
- MRI:
extensive anogenital disease
Differential Diagnosis
- Folliculitis
/ furuncle / carbuncle
- Acne
vulgaris
- Pilonidal
disease
- Perianal
Crohn disease
- Granuloma
inguinale
- TB
abscess, actinomycosis, LGV, syphilis, others
Complications
- Contractures,
strictures
- Genital
/ limb lymphedema
- Chronic
anemia, amyloidosis
- Severe
infection (osteomyelitis, epidural abscess)
- Squamous
cell carcinoma (especially long-standing perianal HS in males)
|
Clinical Pearls
|
Management
Treatment Goals
1.
ลดการเกิด inflammatory
lesions, skin tunnels, scarring
2.
ควบคุมรอยโรคที่เป็นอยู่ (pain,
drainage, odor)
3.
ลดผลกระทบต่อคุณภาพชีวิตและ psychiatric
morbidity
HS เป็นโรคเรื้อรัง → เป้าหมายคือ control,
ไม่ใช่ cure (ยกเว้น localized
surgical cure)
Assessment of Severity & Response
Clinical (daily practice)
- Hurley
stage
- I:
inflammatory nodules/abscesses, no tunnels
- II:
recurrent lesions + tunnels/scars (localized)
- III:
diffuse disease, interconnected tunnels
- ติดตาม:
- จำนวน painful nodules/เดือน
- Pain
score (VAS/NRS)
- QoL
(DLQI, HiSQOL)
Clinical trials / objective
- HiSCR50
/ 75 / 90
- IHS4
Interventions for All Patients
Education & Support
- ไม่ติดเชื้อ, ไม่เกี่ยวกับ hygiene
- โรคเรื้อรัง course แปรปรวน
- ประเมิน depression / anxiety / suicidality
- แนะนำ HS support resources
Wound & Skin Care
- Non-adhesive
dressing, petrolatum
- หลีกเลี่ยง tape
- Antiseptic
wash (chlorhexidine, BPO) →
optional, evidence จำกัด
Pain Management
- NSAIDs
± short-term opioid (selective)
- Chronic
pain →
multidisciplinary approach
Comorbidity Screening (อย่างน้อยปีละครั้ง)
- Metabolic
syndrome, CVD risk
- IBD,
inflammatory arthritis
- PCOS
- Psychiatric
disease
- Smoking,
obesity
Lifestyle
- Smoking
cessation
- Weight
loss (แม้ evidence ต่อ HS ยังไม่ชัด แต่ benefit โดยรวมสูง)
- Metformin
/ GLP-1 RA อาจช่วยทางอ้อม
Treatment by Disease Severity
Hurley Stage I (Mild)
ไม่มี skin tunnels / scarring
Reduce disease burden
First-line
- Oral
tetracyclines
- Doxycycline
100 mg OD–BID × ~3 months
- ± Antiandrogen
(female, menstrual flare / PCOS)
- OCP,
spironolactone
- ± Metformin
(obesity, insulin resistance)
Adjunct
- Topical
clindamycin (rarely sufficient alone)
Acute symptomatic lesions
- Warm
compress
- Intralesional
corticosteroid (triamcinolone 10 mg/mL)
- Punch
debridement
- Topical
resorcinol 15%
🚫 Routine I&D ไม่แนะนำ
Refractory mild disease
- Clindamycin
+ rifampin
- Dapsone
- Acitretin
- Nd:YAG
laser
Hurley Stage II–III (Moderate–Severe)
Initial systemic therapy
- Oral
tetracycline
- If
inadequate → escalate
- Clindamycin
300 mg BID + Rifampin 300 mg BID
- 10–12
weeks (± extend if improving)
- ±
Metformin / Antiandrogen (female)
Failure of Antibiotics / Moderate–Severe Disease
Biologic therapy (preferred)
First-line biologic
- Adalimumab
(anti-TNF)
- 160
mg → 80 mg → 40 mg weekly
- Assess
response at 12–16 weeks
If inadequate / intolerant
- Secukinumab
(IL-17A)
- Bimekizumab
(IL-17A/F)
Alternative
- Infliximab
(IV, off-label)
- Acitretin
(non-childbearing potential)
Severe / Refractory (Hurley III)
- Wide
excision surgery + medical therapy
- Consider:
- IV
ertapenem (rescue)
- Anakinra,
ustekinumab (selected cases)
- JAK
inhibitor (upadacitinib – emerging)
Management of Specific Lesions
Acute severe flares
- Short
course systemic glucocorticoid
- Prednisone
40–60 mg/day → taper
Skin tunnels
- Surgical
unroofing (deroofing) →
high local cure rate
- Wide
excision if extensive
- Intralesional
steroid (small tunnels, rescue)
Special Populations
Pregnancy
- ส่วนใหญ่ stable / improve
- Avoid
oral retinoids
- Individualized
risk–benefit
Children
- Similar
principles
- Avoid
tetracyclines <9 y
- Early
treatment ↓ permanent
scarring
Other / Adjunctive Therapies (Selected)
- Nd:YAG
laser
- Rifampin
+ moxifloxacin + metronidazole (selected)
- Apremilast
- Zinc
supplementation
- GLP-1
receptor agonists (emerging)
Prognosis
- Early
diagnosis = better control
- Hurley
III →
multidisciplinary care
- Surgery
may cure one region but not systemic disease
Red Flag
Squamous Cell Carcinoma (rare but severe)
- Long-standing
HS (especially perianal, males)
- New,
rapidly growing, ulcerative / exophytic lesion → biopsy
|
Key Clinical Pearls
|
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