INTRODUCTION
Hidradenitis suppurativa (HS) is an inflammatory condition that causes painful and disfiguring nodules and abscesses, ultimately resulting in chronic sinus tracts and scar formation. HS is a disease with immense psychosocial repercussions. These include anxiety, depression, social withdrawal, occupational impairment, substance abuse, and a 2-fold increased risk of suicide in HS patients.1 HS lesions most commonly affect intertriginous areas, including the axillae, inframammary crease, groin, and anogenital region. Wide estimates of prevalence are recorded ranging from 0.00033 - 4.10%,2 but there is a clear predilection for women and skin of color,3 Regardless, this condition severely affects the quality of life (QoL) of those affected due to pain and disfigurement.
HS disproportionately affects women, minorities and skin of color.3 Furthermore, many current treatments are minimally efficacious, poorly tolerated, or subject to high recurrence rates.4 This further contributes to the disparity surrounding this patient population. In combination with lifestyle modifications that address weight loss and smoking cessation, antibiotics are first line, but concerns exist regarding antibiotic resistance with studies revealing high levels of resistance in HS patients.4 Surgical intervention with wide local excision is an effective option for those with advanced disease4,5 but is still limited by an average 13% risk of recurrence, although lower than that of other procedures, including local incision and deroofing.5 Biologic therapies are currently in use. Adalimumab is the only biologic approved by the Food and Drug Administration (FDA) for moderate to severe HS,4,6 but others are used off-label with infliximab as an effective, second-line therapy.6 Furthermore, combinations of biologic therapies with other immunosuppressive medications may be more effective than when used alone.4 The risk of infection, cytopenia, malignancy, and hypersensitivity reaction is a concern.6 Other treatments include hormonal and laser therapies, immunosuppressants, retinoids, and antibacterial soaps, such as benzoyl peroxide, all of which have questionable efficacy.4
Botulinum toxin is a relatively unexplored intervention. Given the paucity of evidence surrounding its efficacy, it has received a recommendation class D and evidence level IV.4 To date, no study has reviewed and synthesized the current literature specifically relating to botulinum toxin treatment in HS patients. Here we perform a systematic review of the use of botulinum toxin in HS patients to evaluate treatment characteristics and efficacy, adverse effects, and outcomes with respect to the level of evidence.
HS disproportionately affects women, minorities and skin of color.3 Furthermore, many current treatments are minimally efficacious, poorly tolerated, or subject to high recurrence rates.4 This further contributes to the disparity surrounding this patient population. In combination with lifestyle modifications that address weight loss and smoking cessation, antibiotics are first line, but concerns exist regarding antibiotic resistance with studies revealing high levels of resistance in HS patients.4 Surgical intervention with wide local excision is an effective option for those with advanced disease4,5 but is still limited by an average 13% risk of recurrence, although lower than that of other procedures, including local incision and deroofing.5 Biologic therapies are currently in use. Adalimumab is the only biologic approved by the Food and Drug Administration (FDA) for moderate to severe HS,4,6 but others are used off-label with infliximab as an effective, second-line therapy.6 Furthermore, combinations of biologic therapies with other immunosuppressive medications may be more effective than when used alone.4 The risk of infection, cytopenia, malignancy, and hypersensitivity reaction is a concern.6 Other treatments include hormonal and laser therapies, immunosuppressants, retinoids, and antibacterial soaps, such as benzoyl peroxide, all of which have questionable efficacy.4
Botulinum toxin is a relatively unexplored intervention. Given the paucity of evidence surrounding its efficacy, it has received a recommendation class D and evidence level IV.4 To date, no study has reviewed and synthesized the current literature specifically relating to botulinum toxin treatment in HS patients. Here we perform a systematic review of the use of botulinum toxin in HS patients to evaluate treatment characteristics and efficacy, adverse effects, and outcomes with respect to the level of evidence.
