The patient is a 26 yo man with an eight-year history of
Hidradenitis supprativa (HS). This began in
his axillae but has progressed to groin, perineum and scrotum. He has been treated doxycycline, minocycline,
resection for groin and buttocks sinus tracts three years ago, and lastly Humira for
over the past year, utilizing the standard doses recommended in the literature.* He has constant pain for which he takes oxycodone 20 mg six times a day.
He was seen this week because of continuing pain, drainage and low grade
fever (38 C). He is essentially home bound and is cared for by a devoted mother.
The most affected area at present is his genitalia. He has massive involvement of his scrotum
with inflammatory draining lesions.
Clinical Image:
Impression: Ongoing hidradenitis
stage III mostly affecting the scrotum at this point. The picture is similar to what some label as
“Scrotal Elephantiasis.”
Discussion: I do not think the Humira is impacting on the local disease at this time and he may
need a surgical approach. This could be
ongoing inflammatory disease; but may eventuate into chronic lymphedema. Another possibility is that the resection of the groin lesions may have caused impaired drainage. Against this is the lack of leg edema.
We are looking for therapeutic suggestions and whether any of our
members have successfully treated similar patients. There are a few articles on surgical
approaches in the urology literature.
Follow-up June 16, 2020: Since we last reported on this patient he has had scrotal surgery and has been back on Humira for three months at 40 mg a week. He cannot urinate easily and is home bound. He feels his scrotum is getting worse, but comparison with the photo of June 2019, today's photo is less impressive. We'll see if anyone has helpful suggestions:
Follow-up June 16, 2020: Since we last reported on this patient he has had scrotal surgery and has been back on Humira for three months at 40 mg a week. He cannot urinate easily and is home bound. He feels his scrotum is getting worse, but comparison with the photo of June 2019, today's photo is less impressive. We'll see if anyone has helpful suggestions:
 |
| June 16, 2020 |
References:
1. Scholl L1, et. al. [Surgical
treatment options for hidradenitis suppurativa/acne inversa].
[Article in German] Hautarzt. 2018 Feb;69(2):149-161.
Abstract: Hidradenitis
suppurativa/acne inversa (HS/AI) is a chronic inflammatory skin disease.
Therapy consists of conservative and surgical treatment options. In Hurley
stages II and III, surgical intervention is regarded as the method of choice
for areas with irreversible tissue destruction. Resection techniques with
different grades of invasiveness are described in the literature. Nevertheless,
there is no generally accepted concept regarding resection and reconstruction
techniques or specific postoperative care. Due to lack of definitions of
recurrence after surgery and poor study quality, recurrence rates are difficult
to determine.
2. Kimball AB, et. al. Two Phase 3 Trials of Adalimumab for
Hidradenitis Suppurativa.
N Engl J Med. 2016 Aug 4;375(5):422-34. Full
Free Text.
* The discounted retail cost of Humira for HS (40 mg weekly) is $10,000 USD a month or $120,000 year year.
3. Hormonal therapies for hidradenitis suppurativa: Review.
Clark AK, Quinonez RL, Saric S, Sivamani RK. Dermatol Online
J. 2017 Nov 12;23(10)..
Abstract: Hidradenitis suppurativa is a recurrent
inflammatory skin condition characterized by abscesses and boils, predominantly
in the groin, armpit, and buttocks areas. HS is not a life-threatening
condition, but severely impairs quality of life in those affected. Finding a
successful treatment approach for HS has been challenging, in part because of
the lack of a gold-standard treatment method, limited research-based
information, and the nature of clinical variation in the disease. Treatment
commonly consists of antibiotics, anti-inflammatory therapy, hormonal therapy,
and more invasive clinical procedures. Treatment is chosen by the degree of
severity by which the condition presents and is modified accordingly. This
review describes the roles of hormones in the pathogenesis of hidradenitis
suppurativa and describes the use of hormonal therapy such as, finasteride,
dutasteride, spironolactone, and oral contraceptives. The outcomes of the use
of these modalities in various clinical studies are summarized.
* The discounted retail cost of Humira for HS (40 mg weekly) is $10,000 USD a month or $120,000 year year.
