Laser and light-based treatment options for hidradenitis suppurativa

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Hidradenitis suppurativa (HS) is a chronic inflammatory disease that commonly develops painful, deep dermal abscesses and chronic, draining sinus tracts. Classically, pharmacologic and surgical therapies have been effective for reducing lesion activity and inflammation, but provide only modest success in the prevention of future recurrences and disease progression. Adjunctive therapies, such as laser and light-based therapies, have become more commonly used in the management of HS. These therapies work to reduce the occurrence of painful HS flare-ups by decreasing the number of hair follicles, sebaceous glands, and bacteria in affected areas, and by ablatively debulking chronic lesions. The best results are seen when treatment is individualized, taking disease severity into consideration when selecting specific energy-based approaches. This article will discuss various light-based therapies and the evidence supporting their use in the management of HS.

Introduction

Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the skin that is characterized by the formation of comedones and subcutaneous nodules in apocrine gland–bearing areas that develop into painful, deep dermal abscesses and chronic, draining sinus tracts. These lesions are thought to develop via follicular occlusion, leading to secondary bacterial entrapment and sebaceous and apocrine gland rupture. While pharmacologic and surgical therapies are effective for reducing current lesion activity and inflammation, these therapies provide only modest success in the prevention of future recurrences and disease progression.

In recent years, laser and light-based therapies have become increasingly used in the management of HS. These adjunctive therapies aim to reduce the frequency of painful flares in 2 distinct ways: (1) by decreasing the number of hair follicles, sebaceous glands, and bacteria in affected areas, and (2) by ablatively debulking chronic, problematic lesions. Depending upon a patient's severity of disease, different energy-based approaches are recommended. For example, hair follicle and bacterial load reduction with neodymium-doped yttrium aluminium garnet laser (Nd:YAG) and photodynamic therapy (PDT), respectively, are mainly beneficial for recurrent lesions (Hurley stage I and II); CO2 laser vaporization and excision of sinus tracts are more appropriate for advanced disease (Hurley stage II and III).

This article will discuss the evidence supporting each of the laser and light-based therapies used in the management of HS.

Section snippets

Hair reduction

With the advent of laser-assisted hair reduction devices, new treatment and prevention options have emerged for the management of HS. Laser hair reduction exploits the thermal relaxation time for follicles (40-100 ms) and melanin absorption range (400-1000 nm) to induce selective photothermolysis of hair follicles. To reach the hair bulb and minimize unintentional damage to the epidermal basal layer, longer wavelengths are preferred. Of these devices, the 1064-nm Nd:YAG laser has been studied

Sebaceous gland reduction

After successful reduction in sebaceous gland activity in moderate to severe acne, nonablative radiofrequency was described in 2008 for 1 case of recalcitrant HS affecting the lateral and posterior aspects of the neck (ThermaCool TC; Thermage Inc, Hayward, CA).10 A 50% reduction in HS lesions was noted after the first session, and after 3 sessions, complete resolution was sustained for at least 2 months, eliminating the need for oral or topical treatments. The high fluences (61.5-66 J/cm2)

Bacterial load reduction

In PDT, a photosensitizer (5-aminolaevulinic acid [ALA] or its more lipophilic ester, methyl 5-aminolaevulinate [MAL]) is activated by appropriate wavelengths of visible light to generate cutaneous reactive oxygen species for targeted cell death. A variety of pro- and anti-inflammatory effects, immunomodulatory activities, and antimicrobial properties have also been reported. These form the theoretical basis behind the use of PDT in HS. Unfortunately, attempts to use PDT clinically have shown

Tissue debulking

The CO2 laser (10,600-nm wavelength) has been described as an effective alternative to “cold steel” surgery in the treatment of HS because of minimal removal of unaffected surrounding tissue, improved wound healing, and hemostatic properties that offer better visualization of the operative site.

There are different methods of using the CO2 laser to treat HS. Depending upon disease severity, lesion depth, and provider preference, sinus tracts are either deroofed, vaporized until no affected

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      Citation Excerpt :

      As a continuation of the preconference workshop, Dr Iltefat Hamzavi discussed the use and techniques of various types of laser treatments, including laser hair removal, the alexandrite laser, the CO2 laser, fractional resurfacing, and Nd:YAG in the treatment of HS. Lasers have been shown to be effective in preventing reoccurrence and disrupting disease progression.31 Dr Alexis Lyons also presented promising results of a study evaluating the safety and efficacy of a combination therapy of intense pulsed light with radiofrequency for HS.

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    This publication was supported through funding provided by AbbVie Corporation.

    Drs Hamzavi and Griffith contributed equally to this article.

    Disclosure: Dr Hamzavi receives research support/grants from Microdermis. The other authors have no conflicts of interest to declare.

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