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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Hidradenitis suppurativa &#40;HS&#41; is currently considered an inflammatory disease of the pilosebaceous follicle with an underlying immune system imbalance that affects genetically predisposed individuals&#46; The course of disease can be modified by exogenous triggers or aggravating factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The association between HS and autoimmune and autoinflammatory diseases&#44; such as pyoderma gangrenosum and Crohn disease &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">1</span></a> together with clinical and laboratory findings&#44; supports the existence of an immune system imbalance and consequently suggests inadequate control of the inflammatory response around hair follicles in intertriginous areas&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">HS represents a true therapeutic challenge&#44; with dermatologists responsible for taking decisions regarding patients&#8217; treatment needs&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">General Measures</span><p id="par0020" class="elsevierStylePara elsevierViewall">Numerous general measures can be taken to reduce situations that trigger flares&#44; including tobacco cessation&#44; weight reduction&#44; control of cardiovascular risk factors&#44; avoidance of the use of irritants in affected areas&#44; and hair removal using lasers rather than razors&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">1</span></a> These measures should be complemented by adequate psychological support&#44; which in some cases will need to be intensified&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Local Treatment</span><p id="par0025" class="elsevierStylePara elsevierViewall">The main noninvasive local treatment for localized Hurley stage I or mild stage II lesions is topical clindamycin 0&#46;1&#37; applied every 12<span class="elsevierStyleHsp" style=""></span>hours&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">1&#8211;3</span></a> In one clinical trial&#44; oral tetracycline administered at 500<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h did not show superior results to topical treatment with clindamycin&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">4</span></a> Topical resorcinol 15&#37; has also proven to be effective in reducing the pain and duration of inflammatory lesions in patients with Hurley stage I or II lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">1&#8211;3</span></a> Intralesional corticosteroids are the most common invasive local treatment and the most widely used drug is slow-release triamcinolone acetonide &#40;depot preparation 40<span class="elsevierStyleHsp" style=""></span>mg&#47;mL&#41;&#46; Triamcinolone acetonide injections result in the remission of inflammatory nodules within 48 to 72<span class="elsevierStyleHsp" style=""></span>hours in patients with acute local lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">First-Line Systemic&#47;Biologic Therapies</span><p id="par0030" class="elsevierStylePara elsevierViewall">First-line treatments for HS are treatments supported by high levels of evidence and favorable results&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Systemic Treatments</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Combined Treatment With Oral Clindamycin and Oral Rifampicin</span><p id="par0035" class="elsevierStylePara elsevierViewall">The combined use of clindamycin 300<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h and rifampicin 300<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h for 10 weeks is one of the most common treatments used to induce remission in patients with HS&#44; regardless of disease severity &#40;Hurley stage I&#44; II&#44; or III&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">1</span></a> The beneficial effects of this combination of antibiotics have been confirmed by all series published to date&#44; including a report of 116 patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">5&#44;6</span></a> The therapeutic effect is attributable to the anti-inflammatory properties of the 2 drugs and probably also to their ability to destroy the biofilm mentioned in the first part of this review article&#46; The combination is well tolerated&#44; as the most common adverse effects are gastrointestinal discomfort and diarrhea &#40;generally mild&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Other antibiotics used to treat HS are doxycycline&#44; minocycline&#44; and rifampicin associated with moxifloxacin and&#47;or metronidazole&#44; with variable response&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">1&#8211;3</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Oral Acitretin</span><p id="par0045" class="elsevierStylePara elsevierViewall">The use of acitretin in the treatment of HS is justified by the involvement of psoriasiform hyperplasia in the etiology and pathogenesis of the disease&#46; In a recent study &#40;2014&#41;&#44; Matusiak et al&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">7</span></a> reported on the efficacy of acitretin &#40;mean &#91;SD&#93; dose&#44; 0&#46;56 &#91;0&#46;08&#93; mg&#47;kg&#47;d&#41; in 17 patients with HS&#46; Nine of the patients completed the 9 months of treatment&#44; and 8 &#40;47&#37;&#41; achieved a reduction of 50&#37; from baseline in the Hidradenitis Suppurativa Severity Index&#46; The authors concluded that acitretin appears to be a promising option for the management of HS&#44; although they cautioned that its use might be limited by the high doses required&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Isotretinoin has not proven to be effective in HS&#44; probably because it primarily causes atrophy of hypertrophic sebaceous glands&#44; which are seen in juvenile acne&#44; but not in HS&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">1&#44;7</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Dapsone</span><p id="par0055" class="elsevierStylePara elsevierViewall">Dapsone is a nonteratogenic sulfone antibiotic that has antibacterial and anti-inflammatory &#40;mainly antineutrophilic&#41; properties&#46; In a study of 24 patients with Hurley stage I and II disease&#44; treatment with dapsone at doses of between 50 and 200<span class="elsevierStyleHsp" style=""></span>mg&#47;d resulted in significant clinical improvement in 38&#37; of patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">8&#44;9</span></a></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Biological Therapies</span><p id="par0060" class="elsevierStylePara elsevierViewall">According to the available evidence&#44; the most effective tumor necrosis factor &#945; &#40;TNF-&#945;&#41; blockers in HS are adalimumab and infliximab&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">10</span></a></p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Adalimumab</span><p id="par0065" class="elsevierStylePara elsevierViewall">Adalimumab is supported by the highest levels of evidence &#40;including data from randomized clinical trials&#41; and is considered the most specific treatment for HS&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">10&#8211;12</span></a> Based on the data available&#44; it is currently the main drug for the treatment of refractory Hurley stage II disease or moderate to severe Hurley stage III disease&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Dermatologists are familiar with the use of biologic therapy in the setting of cutaneous and articular psoriasis&#46; The standard doses of adalimumab in these cases are 80<span class="elsevierStyleHsp" style=""></span>mg at week 0&#44; 40<span class="elsevierStyleHsp" style=""></span>mg at week 1&#44; and 40<span class="elsevierStyleHsp" style=""></span>mg every other week thereafter&#46; There are&#44; however&#44; clear differences between psoriasis and HS&#44; mainly related to the level of inflammatory activity &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; In the setting of TNF-&#945;-dependent inflammatory disorders&#44; gastroenterologists use adalimumab administered at doses that are twice as high as those used in psoriasis to treat inflammatory bowel disease &#40;IBD&#41;&#44; and Crohn disease in particular&#44; as this has a higher inflammatory burden&#46; The standard regimen used in this setting is 160<span class="elsevierStyleHsp" style=""></span>mg at week 0 and 80<span class="elsevierStyleHsp" style=""></span>mg at week 2&#44; followed by 40<span class="elsevierStyleHsp" style=""></span>mg administered every week or every 2 weeks&#44; as appropriate&#46; According to the latest data available&#44; HS appears to be closer to the inflammatory spectrum of IBD than of psoriasis&#44; and therefore requires treatment with higher doses of adalimumab than those typically used in dermatology&#59; the response rates would be expected to be similar to those seen in IBD&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Results from the latest trials of adalimumab and HS have shown that&#44; just as in IBD&#44; higher induction and maintenance doses than those used in psoriasis are needed to achieve better disease control&#59; the proposed regimen is 160<span class="elsevierStyleHsp" style=""></span>mg at week 0&#44; 80<span class="elsevierStyleHsp" style=""></span>mg at week 2&#44; and 40<span class="elsevierStyleHsp" style=""></span>mg a week from week 4 onwards&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">12&#8211;15</span></a> These higher doses are justified by the higher levels of TNF-&#945; found in lesional skin in HS compared with psoriasis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">16</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Reports on treatment efficacy for HS are also more similar to those published for IBD than for psoriasis&#46; A retrospective Spanish study of the use of biologic therapy in HS reported complete&#44; lasting remission in approximately 15&#37; of patients and partial remission in approximately 50&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">14</span></a> These data&#44; however&#44; should be interpreted with caution as most patients were administered lower doses than those recommended for HS and IBD&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In a double-blind&#44; randomized&#44; placebo-controlled trial of 154 patients with moderate to severe HS who did not respond to or tolerate tetracycline antibiotics&#44; clinical response was achieved by week 16 in 17&#46;6&#37; of patients treated with adalimumab 40<span class="elsevierStyleHsp" style=""></span>mg weekly&#44; 9&#46;6&#37; of patients treated with adalimumab 40<span class="elsevierStyleHsp" style=""></span>mg every 2 weeks &#40;psoriasis regimen&#41;&#44; and 3&#46;9&#37; of patients treated with placebo&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">12</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">In a more recent phase 3 randomized&#44; placebo-controlled trial &#40;PIONEER II&#41; involving 326 patients&#44; patients were treated with an induction dose of 160<span class="elsevierStyleHsp" style=""></span>mg &#40;week 0&#41;&#44; followed by 80<span class="elsevierStyleHsp" style=""></span>mg at week 2&#44; and 40<span class="elsevierStyleHsp" style=""></span>mg weekly starting at week 4&#46; Response was evaluated using the Hidradenitis Suppurativa Clinical Response &#40;HiSCR&#41; measure&#44; which is defined as a reduction of 50&#37; or more in the count of inflammatory lesions &#40;abscesses and inflammatory nodules&#41; and no increase in abscesses or draining fistulas&#46; At week 12&#44; adalimumab proved to be significantly superior to placebo for the primary endpoint &#40;HiSCR&#41;&#44; with a satisfactory response observed in 50&#37; of patients treated with this biologic&#46; Efficacy was observed at week 2&#44; and the adverse effects were similar to those seen in the placebo group and consistent with the safety profile of adalimumab&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Infliximab</span><p id="par0095" class="elsevierStylePara elsevierViewall">Infliximab is the biologic with the longest tradition in the treatment of HS and its use is supported by high levels of evidence&#44; second only to adalimumab&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">17</span></a> As occurs with adalimumab&#44; the best results are achieved with an intensified regimen of 5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg per month<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">17</span></a> &#40;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg at weeks 0&#44; 2&#44; and 6&#44; and monthly thereafter&#41;&#46; The main disadvantage of infliximab compared with adalimumab is the need to use an intensified regimen&#44; as a majority of patients with HS are overweight or obese&#46; Furthermore&#44; infliximab infusions need to be administered at a day hospital&#46; Formation of antidrug antibodies may be responsible for the reduction in efficacy observed in certain patients with HS treated with infliximab&#44; but levels have not yet been analyzed in this setting&#46;</p></span></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Second-Line Systemic&#47;Biologic Therapies</span><p id="par0100" class="elsevierStylePara elsevierViewall">Treatments supported by a lower level of evidence or associated with less favorable results are considered second-line treatments for HS&#46;</p><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Systemic Therapy</span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Hormone Therapy</span><p id="par0105" class="elsevierStylePara elsevierViewall">There have been isolated case reports of HS responding to contraceptive drugs&#44; such as cyproterone&#44; and antiandrogens&#44; such as finasteride&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">6&#44;18</span></a> Randhawa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">19</span></a> published a report on 3 pediatric patients with HS who responded favorably to finasteride&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In a report on possible medical treatments in 350 patients with HS&#44; Scheinfeld<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">18</span></a> considered that it would be interesting to investigate the use of dutasteride 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#44; as it is a more potent blocker of 5&#945; reductase isoenzyme than finasteride&#44; and in addition&#44; it blocks the type 1 isoenzyme&#44; unlike finasteride&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">6&#44;18</span></a> There are&#44; however&#44; no publications on its use in HS&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Systemic Corticosteroids</span><p id="par0115" class="elsevierStylePara elsevierViewall">Patients with HS&#44; like patients with other inflammatory diseases&#44; experience clinical improvement with systemic corticosteroids&#46; Treatment&#44; however&#44; is limited to short cycles due to the risk of long-term adverse effects&#46; There are no standardized regimens for the use of systemic corticosteroids in HS&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">6&#44;18</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ciclosporin</span><p id="par0120" class="elsevierStylePara elsevierViewall">Ciclosporin&#44; a calcineurin inhibitor&#44; is a potent immunosuppressant that is very active in inflammatory skin diseases&#46; Its targets include T lymphocytes&#44; interleukin &#40;IL&#41; 2&#44; and TNF-&#945;&#46; Contrasting with the situation in psoriasis&#44; only a few isolated reports showing the efficacy of ciclosporin in severe HS have been published&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">1</span></a> The potential of this immunosuppressant in HS should be studied in clinical trial settings&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Methotrexate</span><p id="par0125" class="elsevierStylePara elsevierViewall">Methotrexate has been described as an ineffective drug when used in isolation in HS&#44;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">20</span></a> but it has not been widely studied&#46; It is frequently used in association with TNF-&#945; blockers&#44; and this combination is therefore supported by robust safety data&#46; It would be interesting to evaluate its synergic effect with adalimumab and its potential for lengthening the therapeutic effect of this drug&#44; as it does in psoriasis&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Alitretinoin</span><p id="par0130" class="elsevierStylePara elsevierViewall">Alitretinoin is a retinoid whose therapeutic potential in HS should be investigated for numerous reasons&#58; it has lower teratogenic potential than acitretin due to its shorter half-life and is therefore suitable for use in women of childbearing age&#46; It also has greater immunomodulatory effects due to its rexinoid effect&#46; While it is not cheap&#44; it is not more expensive than biologics&#44; and finally&#44; it is not an immunosuppressant&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">In an Italian study of 14 patients with HS&#44; alitretinoin administered at 10<span class="elsevierStyleHsp" style=""></span>mg&#47;d for 24 weeks resulted in clinical improvement in 78&#46;5&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">21</span></a> It would also be interesting to investigate response rates for the 30-mg&#47;d dose&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Other Treatments</span><p id="par0140" class="elsevierStylePara elsevierViewall">Alternative treatments supported by lower levels of evidence for HS include metformin 500<span class="elsevierStyleHsp" style=""></span>mg&#47;8<span class="elsevierStyleHsp" style=""></span>h&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">1</span></a> sulfasalazine 1<span class="elsevierStyleHsp" style=""></span>g&#47;12<span class="elsevierStyleHsp" style=""></span>h&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">1</span></a> and tacrolimus&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">22</span></a></p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Biologic Therapies</span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Anakinra&#47;Canakinumab</span><p id="par0145" class="elsevierStylePara elsevierViewall">Anakinra is an IL-1 receptor antagonist&#46; Although it is indicated for use in rheumatoid arthritis&#44; it is now largely used as an orphan drug for the treatment of autoinflammatory diseases&#46; IL-1 is a proinflammatory cytokine that is very closely associated with sterile inflammation and neutrophils&#44;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">1&#44;23</span></a> and hence neutropenia features among the drug&#39;s possible adverse effects&#46; Response to anakinra has been reported in isolated cases of HS and in an open-label study of 6 patients&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">1</span></a> However&#44; there have also been reports of treatment failures&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">1</span></a> possibly due to the high levels of IL-1 detected in HS lesions&#44; i&#46;e&#46;&#44; the drug may lack the ability to elicit a response in certain patients &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Anakinra is normally administered subcutaneously at a dose of 100<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#44; but there has been a report of a patient responding to a dose of 200<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">1</span></a> Local reactions are the main problem associated with the use of anakinra&#44; although these tend to improve after 4 weeks of treatment&#46; Anakinra should not be used in association with TNF-&#945; blockers&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Canakinumab is a fully human IgG&#954; monoclonal antibody targeting IL-1&#946;&#46; It selectively binds to IL-1&#946; with high affinity&#44; neutralizing its biological activity by blocking interaction with IL-1 receptors and preventing the production of inflammatory mediators&#46; It is indicated in autoinflammatory syndromes&#44; systemic juvenile idiopathic arthritis&#44; and arthritic gout&#46; It has an advantage over anakinra is that it is administered subcutaneously every 4 or 8 weeks&#46; There has been a report of satisfactory response to canakinumab in a patient with HS and pyoderma gangrenosum&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">23</span></a> However&#44; its high cost is a deterrent for the conduct of larger studies in HS&#46;</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Ustekinumab</span><p id="par0155" class="elsevierStylePara elsevierViewall">Ustekinumab is a biologic that targets the p40 subunit of IL-12&#47;IL-23&#46; It has proven effective in the treatment of isolated cases of HS&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">1</span></a> Like adalimumab and infliximab&#44; it is probably more effective when administered at an intensified regimen consisting of 90-mg doses every 2 months&#59; this is supported by a report of treatment failure when administered at the lower dose used for psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">25</span></a></p></span></span></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Surgical Treatment</span><p id="par0160" class="elsevierStylePara elsevierViewall">Surgery is indicated for the treatment of nodules and isolated fistulas and for severe&#44; extensive disease that does not respond to medical treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">1&#44;26&#44;27</span></a> Its effectiveness&#44; however&#44; has not yet been evaluated in clinical trials&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">27</span></a> Additionally&#44; while the literature shows that surgery appears to achieve good results in milder forms of HS&#44; high recurrence rates have been observed in patients with moderate or severe disease and high levels of cutaneous and systemic inflammation treated with surgery only&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Several surgical techniques are indicated for HS&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0235" class="elsevierStylePara elsevierViewall">Incision and drainage</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0240" class="elsevierStylePara elsevierViewall">Unroofing and marsupialization</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0245" class="elsevierStylePara elsevierViewall">Localized excision</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0250" class="elsevierStylePara elsevierViewall">Wide excision</p></li></ul></p><p id="par0165" class="elsevierStylePara elsevierViewall">The choice of surgery and size of margins are determined by the area affected and the degree of involvement&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Preoperative care</span>&#46; Prior reduction of inflammation is recommended in patients with high degrees of inflammation and unclear margins&#46; A 10-to-12-week course of antibiotics is probably sufficient for mild and moderate cases&#44; but a short cycle of oral corticosteroids can also be added&#46; Patients with severe disease can be administered prednisone 40-60<span class="elsevierStyleHsp" style=""></span>mg&#47;d for 2 to 3 days followed by a decreasing dose over an additional 10 to 12 days&#46; Ciclosporin has also been used&#44; as have TNF-&#945; blockers&#46; General hygiene and dietary measures are recommended in all cases&#46;</p><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Incision and Drainage</span><p id="par0175" class="elsevierStylePara elsevierViewall">Incision with drainage is a simple technique that can be performed under local anesthesia on an outpatient basis&#46; It tends to result in rapid relief of pain in the case of isolated nodules&#44; but recurrence is common&#46;<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">28&#44;29</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Punch debridement has also been proposed as a modification of this technique&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">30</span></a> This procedure involves centering a biopsy punch with a diameter of 5 to 7<span class="elsevierStyleHsp" style=""></span>mm over an inflamed pilosebaceous unit&#44; which is then debrided by digital pressure followed by curettage&#46; The goal is to remove the remains of the sebaceous gland and&#47;or the follicle containing cells involved in the generation of fistulas and fibrous tracts&#46; Preliminary data suggest that recurrences are relatively infrequent with this technique&#46;</p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Unroofing</span><p id="par0185" class="elsevierStylePara elsevierViewall">Unroofing &#40;or deroofing&#41; with marsupialization is a simple technique that can also be performed on an outpatient basis&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">31</span></a> In this technique&#44; the fistulous tract or roof of a nodule is transfixed using a probe or a mosquito forceps&#59; the tissue is then removed with the aid of a scissors&#44; electric scalpel&#44; or radiofrequency ablation&#44; thereby exposing the bed of the lesion&#44; which is scraped with a curette&#46; The lesions are left to heal by secondary intention&#46; Unroofing is suitable for recurrent painful stage I or II lesions&#44; and results in acceptable cosmetic results&#46; Approximately 17&#37; of lesions treated using this technique have been found to recur within a mean of 4 to 6 months&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">31&#44;32</span></a></p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Local Excision</span><p id="par0190" class="elsevierStylePara elsevierViewall">Local excision has the same advantages and disadvantages as incision and drainage&#46;</p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Wide Excision</span><p id="par0195" class="elsevierStylePara elsevierViewall">Wide excision involves removing an entire affected area with margins extending beyond the visibly affected region&#46; When used in combination with medical measures and treatments&#44; wide excision is the technique that is most likely to achieve disease control in patients with chronic&#44; extensive stage III disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">1&#8211;29</span></a> The surgical defect can be reconstructed using simple local or free flaps&#44; skin grafts&#44; tissue expanders&#44; or simply closure by secondary intention&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">33</span></a> Assuming that adequate margins can be guaranteed&#44; the reconstruction method does not influence recurrence rates and should therefore be chosen according to the site of excision and the size of the lesion&#46;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">34&#44;35</span></a> Margins of between 0&#46;5<span class="elsevierStyleHsp" style=""></span>cm &#40;axillae&#41; and 1&#46;5<span class="elsevierStyleHsp" style=""></span>cm are recommended&#46; Deep excision extending as far as the fascia or at least 5<span class="elsevierStyleHsp" style=""></span>mm of fat is important to ensure removal of the deep coils of the apocrine glands&#46; Wide excision&#44; however&#44; does not protect against recurrence at distant apocrine sites&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Several authors advise against using primary closure techniques due to the high risk of recurrence &#40;54&#37;-69&#46;9&#37; vs 13&#37; for grafts and 18&#37; for local flaps&#41;&#44; but these higher rates are attributable to the higher number of affected margins or to incomplete resection&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">26</span></a> Nonetheless&#44; significant differences have been reported for recurrence rates associated with different reconstruction techniques&#44; but it is difficult to compare modalities due to the nature of HS and the number of techniques that exist&#46; Some studies that have assessed recurrence rates by location have reported lower rates in the axillae &#40;3&#37;&#41; and perianal area &#40;0&#37;&#41; than in the groin and perineal region &#40;37&#37;&#41; and submammary area &#40;50&#37;&#41;&#44; suggesting that recurrence is more common at sites with larger areas of apocrine glands&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">26</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Vacuum-assisted closure involves the use of a device that delivers negative pressure to the wound and therefore promotes blood flow&#44; increases the rate of granulation tissue formation&#44; and facilitates wound drainage&#44; thereby reducing bacterial load&#46; This technique has been found to produce better results and lower rates of recurrence when used in larger wounds&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">36</span></a></p></span></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Lasers and Light</span><p id="par0210" class="elsevierStylePara elsevierViewall">A range of laser and light systems have been used in HS&#44; with varying results&#46; Carbon dioxide laser therapy results in improvement by clinically vaporizing all the layers of tissue as far as the deep subcutaneous fat or fascia&#46; Recurrence is low&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">37</span></a> Hair removal lasers and intense-pulsed light systems also result in clinical improvement by reducing the number of hair follicles and associated inflammation&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">38</span></a> Long-pulsed &#40;1064<span class="elsevierStyleHsp" style=""></span>nm&#41; Nd&#58;YAG 1064 laser therapy has also been described as effective for the treatment of Hurley stage II and III disease&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">39</span></a> Finally&#44; reports describing the use of photodynamic therapy in series of patients with HS have increased&#44;<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">40&#8211;42</span></a> but the results are varied and recurrence is high&#46; A standardized photodynamic treatment regimen has not been described&#46;</p></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Other Treatments</span><p id="par0215" class="elsevierStylePara elsevierViewall">Radiation therapy is no longer used to treat HS due to the risk of tumors and the existence of alternative treatments&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">43</span></a> However&#44; classic studies of this technique show complete remission in 38&#37; of cases and improvement in 40&#37;&#46; Cryotherapy has proven effective in the management of isolated cases of painful HS nodules&#44; as has cryoinsufflation&#44; which involves applying liquid nitrogen into small fistulous tracts using a needle that follows the path of the fistula&#44; followed by 2 freeze cycles in the entire area&#46;<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">43&#44;44</span></a> Unfortunately&#44; recovery time is long and the treatment is quite painful&#46;</p></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Conclusions&#58; Towards a Treatment Algorithm</span><p id="par0220" class="elsevierStylePara elsevierViewall">Our review of the different treatment options for HS shows that <span class="elsevierStyleItalic">a</span>&#41; HS is a chronic skin disease with a significant systemic component &#40;largely in moderate and severe forms of the disease&#41; that needs to be controlled medically&#59; <span class="elsevierStyleItalic">b</span>&#41; HS is an inflammatory disease that needs to be treated with a combination of topical and systemic&#47;biologic treatments and&#44; occasionally&#44; surgery of varying levels of complexity&#59; and <span class="elsevierStyleItalic">c</span>&#41; HS is a disabling disease whose management can be optimized by designing personalized therapies overseen by dermatologists with the involvement of primary care physicians&#44; surgeons&#44; and nursing staff&#44; and occasional collaboration from other specialists&#44; such as psychologists and gastroenterologists&#44; among others &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">45</span></a> Recent data regarding the efficacy of adalimumab in HS&#44; combined with the recent approval of this drug by the European Medicines Agency as a primary specific treatment for HS&#44; will help us to manage cases that require maintenance therapy to achieve optimal control of inflammation&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Conflicts of Interest</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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                  "titulo" => "Combined Treatment With Oral Clindamycin and Oral Rifampicin"
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              "titulo" => "Incision and Drainage"
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              "titulo" => "Unroofing"
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              "titulo" => "Local Excision"
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          "titulo" => "Lasers and Light"
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    "fechaRecibido" => "2015-05-04"
    "fechaAceptado" => "2015-06-30"
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            0 => "Hidradenitis suppurativa"
            1 => "Acne inversa"
            2 => "Surgery"
            3 => "Biologic therapy"
            4 => "Systemic treatment"
            5 => "Adalimumab"
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            0 => "Hidradenitis supurativa"
            1 => "Acn&#233; inversa"
            2 => "Cirug&#237;a"
            3 => "Terapia biol&#243;gica"
            4 => "Terapia sist&#233;mica"
            5 => "Adalimumab"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Although hidradenitis suppurativa is a common and serious skin condition&#44; its treatment is not well established&#46; It is now accepted that the moderate and severe forms of the disease are associated with marked systemic inflammation&#46; The goal of treatment in hidradenitis suppurative is therefore to achieve systemic control of inflammation&#46; In some cases&#44; surgery may also be necessary to reduce the severity of the manifestations of cutaneous inflammation&#46; Recent advances in our understanding of hidradenitis suppurativa have been accompanied by the emergence of novel approaches to its treatment&#44; including the use of certain biologic drugs&#46; Several clinical trials have been undertaken to test the effects of biologics &#40;mainly adalimumab&#41; in this setting&#46; In this review&#44; we analyze the different treatments available for hidradenitis suppurativa&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A pesar de la importancia y de la gravedad de la hidradenitis supurativa&#44; el tratamiento de esta enfermedad no se encuentra bien definido&#46; Hoy en d&#237;a&#44; la hidradenitis es considerada una enfermedad cut&#225;nea que principalmente en las formas moderadas y severas se asocia a un marcado componente inflamatorio sist&#233;mico&#46; Por lo tanto&#44; el tratamiento de esta enfermedad ir&#225; enfocado hacia un manejo sist&#233;mico del control de la inflamaci&#243;n&#44; que ocasionalmente ir&#225; acompa&#241;ado de la intervenci&#243;n quir&#250;rgica para reducir la carga de inflamaci&#243;n localizada en la piel&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Los recientes avances en el conocimiento de la enfermedad se han acompa&#241;ado de novedades terap&#233;uticas&#44; especialmente representadas por el desarrollo de ensayos cl&#237;nicos de determinadas terapias biol&#243;gicas&#44; principalmente adalimumab&#44; orientados al tratamiento espec&#237;fico de esta enfermedad&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">En la presente revisi&#243;n se pretende analizar las diferentes alternativas terap&#233;uticas existentes en el manejo de la hidradenitis supurativa&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Martorell A&#44; Garc&#237;a FJ&#44; Jim&#233;nez-Gallo D&#44; Pascual JC&#44; Pereyra-Rodr&#237;guez J&#44; Salgado L&#44; et al&#46; Actualizaci&#243;n en hidradenitis supurativa &#40;<span class="elsevierStyleSmallCaps">ii</span>&#41;&#58; aspectos terap&#233;uticos&#46; Actas Dermosifiliogr&#46; 2015&#59;106&#58;716&#8211;724&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Comparative levels of proinflammatory cytokines &#40;in number of times increased&#41; in the skin of patients with hidradenitis suppurativa compared with psoriasis&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Treatment algorithm for hidradenitis suppurativa&#46;</p> <p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Source&#58; Martorell&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">45</span></a></p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cutaneous psoriasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Hidradenitis suppurativa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Less inflammation and easier to control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Greater inflammation and more difficult to control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Does not hurt but can cause itching&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Painful and oozes pus &#40;bad smell and stains clothes&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Not disabling &#40;except for psoriatic arthritis&#41; and does not cause scarring&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Disabling and leaves permanent scars&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Less impact on quality of life&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Greater impact on quality of life&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cannot degenerate into cancer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cancer can arise &#40;chronic inflammation&#41; in HS lesions&#44; predominantly in the perianal and gluteal region&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Classic and biologic therapies &#40;with summary of product characteristics and supported by studies with higher levels of evidence&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adalimumab&#44; only treatment with recommended approval from the European Medicines Agency following completion of randomized clinical trials&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Differences Between Cutaneous Psoriasis and Hidradenitis Suppurativa That Influence Treatment of the Latter&#46;</p>"
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      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
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