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Therapeutic Strategies

Hidradenitis Suppurativa and Perifolliculitis Capitis

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

Perifolliculitis Capitis Abscedens et Suffoidiens/Dissecting Cellulitis of the Scalp

Hidradenitis suppurativa and perifolliculitis capitis are chronic inflammatory processes that affect the groin, axilla, and inframammary areas (hidradenitis suppurativa) and the scalp (dissecting cellulitis). Progression is often relentless and defies medical management. Early surgery for local and widespread lesions is often the best alternative.

First Steps

Medical

  1. Culture draining sinus tracts or abscesses for aerobic and anaerobic bacteria.
  2. Give full-dose oral antibiotics effective against the isolated organisms for 1 month. Tetracycline, amoxicillin, penicillin, dicloxacillin, cephalosporins, and clindamycin have all been used with variable results.
  3. Prescribe topical clindamycin solution to be applied to the affected areas twice daily.

Surgical

  1. Incise and drain fluctuant abscesses.
  2. Inject triamcinolone acetonide 5-10 mg/cc into all nonfluctuant inflammatory areas. This may be repeated at intervals of 2-4 weeks.
  3. Local areas may be totally excised, if small, with good results.

Ancillary Steps

  1. Encourage obese patients with disease in the intertriginous areas to lose weight.
  2. Oral zinc sulfate 220 mg three times daily may be beneficial. In one case of perifolliculitis capitis, complete healing resulted.

Subsequent Steps

Initial positive response

  1. Continue oral antibiotics and taper them slowly over 6-12 months. If the disease recurs, reculture and repeat initial management.
  2. Because relapse and persistence is the rule, even patients who have responded well to conservative therapy may be offered more extensive surgical procedures, especially for axillary disease (see below).

Initial treatment failure

  1. Medical treatment a. Systemic corticosteroids (prednisone 0.5-1 mg/kg/day) for several weeks will significantly reduce inflammation. When combined with appropriate antibiotics, corticosteroids may also allow the disease to be controlled. b. Isotretinoin 1-2 mg/kg has been effective in some patients. When there is no contraindication, a course should be attempted. c. For severe recalcitrant dissecting disease of the scalp, low-dose x-ray epilation (Adamson-Keibock technique) will usually at least temporarily control severe recalcitrant disease.
  2. Surgical treatment Extensive surgical procedures usually offer the only hope for the severely affected. a. For axillary disease, total excision of the affected axillary areas is of only moderate morbidity and gives excellent results. After their convalescence, patients are, in general, quite happy with the long-term, usually permanent remission. b. Genitocrural hidradenitis can also be totally excised, but often extensive grafting or prolonged healing is required owing to the large areas of involvement. Despite this, after convalescence most patients are satisfied. c. Total excision of the affected scalp in dissecting cellulitis of the scalp is also effective, and often curative. Patients are usually rendered permanently bald, so a hairpiece may be required.

Pitfalls

  1. These disease processes are aggressive, and they require aggressive management to obtain disease control.
  2. Tetracycline is contraindicated in pregnancy.
  3. With high-dose zinc sulfate, GI upset is common.
  4. Patients face a twofold risk of carcinoma in these conditions. If the disease is chronic, squamous cell carcinomas, which may be fatal, may occur. In addition, there is an increased risk of cutaneous carcinoma in the radiation-treated areas, especially in patients with white skin. Any suspicious nonhealing lesion requires biopsy.
  5. Inflammatory bowel disease may cause perirectal and/or genital sinus tracts and abscesses. These may be misdiagnosed as hidradinitis.

 

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