Pain Management of Refractory Hidradenitis Suppurativa: Case Report
Main Article Content
Keywords
pain management, hidradenitis suppurativa, chronic, multidisciplinary care, quality of life
Abstract
Background: Hidradenitis suppurativa (HS) is a chronic, relapsing, and painful inflammatory condition of the skin. Pain in HS is one of the most common symptoms and has a devastating effect on quality of life. Here, we present a unique case of a patient with HS and pain management guidelines used to treat her condition.
Case Report: This is a 42-year-old woman with a history of HS, hypertension, depression who presented with one month of pain in her groin crease, vulva, and rectum. She was recently discharged from the hospital for HS superinfection. She was treated with intravenous and oral antibiotics. She previously tried treatment with acetaminophen, lidocaine 2% jelly, gabapentin 400 mg TID, oxycodone, dilaudid, adalimumab, infliximab, topical clindamycin, intralesional steroid injections, and doxycycline. The pain management specialist recommended continuing treatment with gabapentin 400 mg TID and titrate to 600 mg TID as tolerated, and to follow up with the dermatology team to restart infliximab.
Discussion: This case demonstrates a complicated, refractory HS condition that necessitates first, second, and third line treatment modalities. Pain control in HS starts by having best control of the underlying disease. The United States and Canadian Hidradenitis Suppurativa Foundations clinical guidelines suggest acute pain management should include topical analgesics (ie, lidocaine), oral acetaminophen, and oral nonsteroidal anti-inflammatory drugs. Chronic pain management should focus on a multidisciplinary approach. Clinical guidelines recommend escalating oral analgesics for pain that doesn’t respond to first-line agents. Opiate use should follow the World Health Organization pain ladder of tramadol, codeine, hydrocodone, and morphine. Neuropathic pain can be treated with pregabalin or gabapentin, titrated as tolerated by patients. Chronic HS lesions can be treated with wide local scalpel, CO2, or electrosurgical excision, and recurrent nodules can be deroofed or excised. Superior hypogastric plexus block and/or ganglion impar block can be considered for refractory cases.
Conclusion: HS is an extremely painful condition severely affecting quality of life. Adequate pain management is vital, and a stepwise approach is recommended.
References
2. van Straalen KR. Chronic Pain in Hidradenitis Suppurativa Explained Through the Process of Central Sensitization. JAMA Dermatol. Jun 1 2020;156(6):615-616. doi:10.1001/jamadermatol.2020.0225
3. Horvath B, Janse IC, Sibbald GR. Pain management in patients with hidradenitis suppurativa. J Am Acad Dermatol. Nov 2015;73(5 Suppl 1):S47-51. doi:10.1016/j.jaad.2015.07.046
4. Tchero H, Herlin C, Bekara F, Fluieraru S, Teot L. Hidradenitis Suppurativa: A Systematic Review and Meta-analysis of Therapeutic Interventions. Indian J Dermatol Venereol Leprol. May-Jun 2019;85(3):248-257. doi:10.4103/ijdvl.IJDVL_69_18
5. Alikhan A, Sayed C, Alavi A, et al. North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations: Part I: Diagnosis, evaluation, and the use of complementary and procedural management. J Am Acad Dermatol. Jul 2019;81(1):76-90. doi:10.1016/j.jaad.2019.02.067
6. Fernandez JM, Thompson AM, Borgstrom M, Orenstein LAV, Hsiao JL, Shi VY. Pain management modalities for hidradenitis suppurativa: a patient survey. J Dermatolog Treat. May 2022;33(3):1742-1745. doi:10.1080/09546634.2020.1822501
7. Ingram JR, Collier F, Brown D, et al. British Association of Dermatologists guidelines for the management of hidradenitis suppurativa (acne inversa) 2018. Br J Dermatol. May 2019;180(5):1009-1017. doi:10.1111/bjd.17537
8. Magalhaes RF, Rivitti-Machado MC, Duarte GV, et al. Consensus on the treatment of hidradenitis suppurativa - Brazilian Society of Dermatology. An Bras Dermatol. Apr 2019;94(2 Suppl 1):7-19. doi:10.1590/abd1806-4841.20198607
9. Alavi A, Lynde C, Alhusayen R, et al. Approach to the Management of Patients With Hidradenitis Suppurativa: A Consensus Document. J Cutan Med Surg. Nov/Dec 2017;21(6):513-524. doi:10.1177/1203475417716117
10. Urits I, Schwartz R, Herman J, et al. A Comprehensive Update of the Superior Hypogastric Block for the Management of Chronic Pelvic Pain. Curr Pain Headache Rep. Feb 25 2021;25(3):13. doi:10.1007/s11916-020-00933-0
11. Swain BP, Vidhya S, Kumar S. Ganglion Impar Block: A Magic Bullet to Fix Idiopathic Coccygodynia. Cureus. Jan 2023;15(1):e33911. doi:10.7759/cureus.33911
12. Le Clerc QC, Riant T, Levesque A, et al. Repeated Ganglion Impar Block in a Cohort of 83 Patients with Chronic Pelvic and Perineal Pain. Pain Physician. Sep 2017;20(6):E823-E828.