Topical treatment

Topical or local therapy is traditionally often used in dermatology. It holds a number of advantages over systemic therapy, primarily by reducing the risk of a number of side-effects and being easy for the patients to administer themselves, but also its low cost. On the other hand, topical or local therapy is often less potent than systemic therapy when dealing with more generalized or recalcitrant diseases. Accurate assessment of disease severity is therefore of importance when choosing therapy. In hidradenitis suppurativa (HS), topical therapy is best used in very early lesions or for the maintenance of a therapeutic result. In contrast, intralesional or local therapy is better suited for early advancing or intermediate lesions, before switching to surgery or systemic therapy. The choice of topical/local versus systemic therapy therefore depends not only on the individual characteristics of the patient and the disease, but also on the developmental stage of the disease. Several different types of topical therapy have been tried in HS, although there are few actual trials. The paucity of trials opens the possibility of biased reporting of results, and therefore slows the development of new treatments. Antibiotics have been extensively used, and form a mainstay of early therapy with some of the few controlled trials in HS. Keratolytics have also been used because of the histological similarities between HS and acne, although the evidence base for this is more restricted. Finally, anti-inflammatory preparations are on occasion helpful to patients when applied to predisposed areas as preventive or adjuvant therapy. In contrast, intralesional therapy with corticosteroids is frequently used, and often effective at treating individual recalcitrant lesions. Failing local pharmacological therapy, minor local surgical procedures may be of help to some patients. This spectrum of therapies will be reviewed in this chapter.