Pain management in Hidradenitis Suppurativa (HS) addresses both acute and chronic pain that can be present in active disease caused by inflamed nodules, cysts, or abscesses. This pain can make it difficult to do daily things, attend work, or exercise. Pain can be further categorized as nociceptive, stimulant-dependent, and neuropathic. Treatments involve a combination of pharmacologic and non-pharmacologic strategies.1

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For acute pain, treatment goals include managing inflammation and providing symptomatic relief. Lidocaine is available as a topical analgesic. Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are available as oral agents.1,2 Topical therapies with lidocaine or menthol can reduce pain associated and are often well tolerated.3

Opioids may be used in severe cases of acute pain but may not be preferred depending on patient preference. Opioid options include codeine, hydrocodone, and morphine. Patients may seek an alternative to conventional opioids, especially those with cardiovascular or pulmonary comorbidities. One alternative treatment option is tramadol, as it allows for NSAID-sparing effects.1.

Chronic pain management varies from acute as it often requires a multidisciplinary approach; sometimes involving pain specialists.

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Non-pharmacologic pain management, such as cognitive behavioural therapy, should be the first approach to chronic pain.3 Psychological comorbidities, including depression and anxiety, significantly impact pain perception and quality of life in HS patients. In these scenarios, non-pharmacologic treatment can offer some relief for patients. Non-pharmacologic options could include addressing patient-specific issues with psychological education and patient support groups. Having a strong support network involving friends and family can help patients cope with their HS symptoms.4

For neuropathic pain specifically, anticonvulsant medications such as pregabalin and gabapentin are effective. Anticonvulsants should be used with caution due to potential side effects.1,2 Another option for neuropathic pain could be selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). SSRIs and SNRIs can provide relief for neuropathic pain and have beneficial effects on associated depression and anxiety.2

Alternative therapies that can be used in pain management of HS are cannabinoids, intralesional corticosteroid injections in areas of active disease to decrease inflammation, dressings to relieve pressure, or surgery for temporary relief of pressure and pain by removing pus.3

Overall, pain management in HS involves a variety of different treatments that range from topical and systemic analgesics, neuropathic medications, or surgical procedures to relieve pressure. Additionally, addressing psychological comorbidities is a crucial component to improving overall quality of life and managing pain in HS.

References

  1. 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. Alikhan A, Sayed C, Alavi A, et al. Journal of the American Academy of Dermatology. 2019;81(1):76-90. doi:10.1016/j.jaad.2019.02.067.
  2. Pain Management in Patients With Hidradenitis Suppurativa. Horváth B, Janse IC, Sibbald GR. Journal of the American Academy of Dermatology. 2015;73(5 Suppl 1):S47-51. doi:10.1016/j.jaad.2015.07.046.
  3. Leah Johnston EA, Poelman Associate Editors Rochelle Tonkin SM, Bourcier M, Alhusayen R. A Guide to Hidradenitis Suppurativa: Living with HS.; 2022.
  4. Quality of Life Considerations and Pain Management in Hidradenitis Suppurativa. Jemec GB. Seminars in Cutaneous Medicine and Surgery. 2017;36(2):75-78. doi:10.12788/j.sder.2017.016.

Submitted by: Kae Fraser

Submitted Jan 21, 2025

Word count: 393