Managing Pain in Patients with Hidradenitis Suppurativa (HS)

There are many aspects of HS that affect patient’s quality of life, and pain is typically one of the most important factors.  While patients may have variable experiences with pain as part of their HS, it is a nearly constant concern.  Some patients may experience daily pain when their disease is poorly controlled, and for others it can be limited to days when the disease is more active.  Pain following surgical procedures for HS is also a given in most circumstances.  Considering this, both acute and chronic pain management are important aspects of patient care.  General practitioners and dermatologists may have variable comfort levels managing pain in HS so, in some instances, consultation with pain management specialists may be helpful.  Optimal pain relief strategies have not been well-studied, but based on our knowledge of pain management there are usually ways to reduce the burden of pain that patients experience.

Topical therapy:

In general, topical pain relievers have not been evaluated specifically for HS. Despite this, based on our knowledge of these medications for the treatment of arthritis and other painful conditions effecting muscle and joints, there is likely to be some benefit for patients with HS. In general, direct application to open skin wounds should be avoided.

Topical anesthetics such as over-the-counter and prescriptions containing lidocaine, prilocaine, and tetracaine are readily available, but used infrequently for HS.  Preparations of lidocaine cream (i.e.,  4% lidocaine marketed as LMX cream) typically have onset over 30-60 minutes and can lead to temporary pain reduction lasting up to 2 hours if the cream is not removed.  These can be used prior to procedures to reduce pain of injections, or for areas of disease activity that are painful.  Lidocaine is preferable to prilocaine and tetracaine as it is less likely to cause internal side effects from absorption through the skin.  Aspercreme is a 4% lidocaine cream available over the counter that can be used three times daily, and some higher strength preparations of creams, ointments, and patches are available as prescriptions.  Up to three patches can be applied daily for 12 hours and replaced each day to provide 24-hour pain relief.  Insurance coverage is sometimes a challenge for lidocaine patches.  Pain related to deeper abscesses may be less responsive to treatment.

Diclofenac (also known as Voltaren) 1% gel is another prescription option that helps to reduce inflammation and pain and is a topical NSAID (anti-inflammatory medication).  Application for joint pain has led to improvement similar to the use of oral diclofenac, but with fewer side effects since only approximately 2-6% is absorbed).  Its use for HS has not been studied, but it is likely to be helpful in reducing pain.  It comes with a ruler for easy dosing, and can be used up to four times per day.  It is also available as a 1.3% diclofenac  patch (also known as Flector) and can be placed every 12 hours over the area of pain.

Other combinations of topical pain medications can be compounded at the recommendation of experienced providers by specialized pharmacies.  Topical formulations including amitriptyline, ketamine, bupivacaine, gabapentin, doxepin, and others have been reported as helpful in various painful conditions, but safety and efficacy have not been demonstrated in HS.  Insurance coverage is typically limited for compounded medications and cost is often restrictive.

Oral, non-opiate pain medications:

Acetaminophen is safe and effective for many types of pain.  1,000 mg taken every 8 hours or 650mg every 6 hours (no more than 3,000 mg daily) may be effective for controlling pain in hidradenitis suppurativa.  Dosing less than 3,000mg a day can be used daily and chronically safely (in the absence of liver disease).  It can still be used in patients with a history of liver disease, but typically at lower doses.  It can be combined with NSAIDS and opiate analgesics when needed.

NSAIDs

Ibuprofen is another readily available over-the-counter pain medication. Doses starting at 400 mg every 8 hours and increased to 800 mg every 8 hours as needed or 600mg every 6 hours as needed can help reduce pain related to inflammation in HS.  Over-the-counter naproxen sodium taken 250-500 mg twice daily may have a similar effect.  Combining acetaminophen and ibuprofen has been found to be equally successful as combinations of acetaminophen and opiate medications following skin surgery and is a safer alternative for most patients.

Prescription NSAIDs such as diclofenac, ketorolac, meloxicam, indomethacin, and celexocib can be used for pain control when over-the-counter options are ineffective or limited by side effects.

New FDA guidelines about NSAIDs came out in July 2015, which discourages their chronic use due to safety concerns related to heart attack and stroke adverse events, on top of the well-known gastrointestinal and renal (kidney) safety issues.  Topical NSAIDs (Voltaren gel and Flector patch) can be used chronically safely, but oral NSAIDs should be limited to 1-2 week courses at most unless discussed with your physician.  Due to the risk of the above side effects with prolonged NSAID use it is highly recommended that patients discuss prolonged use with their physicians to help monitor for and limit complications.  Patients with liver or kidney disease should also discuss use of these drugs with a physician.

Antiepileptics:

Gabapentin and pregabalin – these drugs work to reduce the nerve signals that transmit pain.  Gabapentin (Neurontin) must be taken more frequently, but is much less expensive than pregabalin.  Gabapentin starting at 100mg three times daily and increasing up to a maximum of 1200 mg three times daily can lead to significant pain relief. Most patients will have adequate relief at a dose of 300–600 mg three times daily.  Pregabalin (Lyrica) is typically started at 25-50mg twice a day and increased as tolerated to effect of a maximum dose of 600mg per day (either 300mg twice a day or 200mg three times a day) is similarly effective for many patients and may result in less drowsiness than gabapentin.  Both drugs have been linked to depression and suicide risk in a very small number of patients, but both are typically safe and well-tolerated for treating many painful conditions.  They also have almost no medication interaction compared to other similar medications.  Patients with kidney disease have to be on lower doses.  Patients taking the drug for extended periods of time should slowly reduce their dose over time as withdrawal symptoms are possible.

Antidepressants:

SNRI’s (Duloxetine and venlafaxine) – these are antidepressant drugs that also work to reduce transmission of pain signals and anxiety that may lead to increased perceptions of pain.  While often successful at treating pain syndromes, side effects such as weight gain, nausea, and somnolence sometimes limit their use.  Duloxetine (Cymbalta) is typically considered to be a safe option at 30-60 mg daily (rarely doses as high as 90-120mg).  Some patients find it activating (unlike most pain medications that are sedating) and so it is commonly dosed in the morning.  It is sometimes well covered by insurance, but sometimes patients have to try an alternative first.   Venlafaxine XR (Effexor) at doses of 75-225 mg daily is similarly effective, but is associated with cardiovascular side effects that sometimes are a limiting factor.  It is typically less expensive than duloxetine, and so sometimes is the preferred agent by insurance.

Tricyclic antidepressants (TCA’s i.e., amitriptyline, nortriptyline, and desipramine) have been used to treat chronic pain in many conditions, mainly neuropathic (nerve) type pain.  They are not used as frequently for depression, and are used at much lower doses for pain.  They tend to be less expensive, and are even on many $4 medication lists at major pharmacies.   The most common side effect is typically sedation, so they can also be beneficial for sleep.  They have other side effects which can sometimes limit their use in older patients or patients with many medical conditions.  These are less frequently used for pain management in hidradenitis suppurativa, but may be considered for some patients.

SSRIs (i.e., sertraline, citalopram, fluoxetine) are a staple in the treatment of anxiety and depression, but they are not as beneficial as medications like duloxetine, venlafaxine, and the TCA’s.

Opioids (narcotic pain medication):

Opioid analgesics are typically reserved for patients with severe pain related to acute injuries, disease flares or following surgical interventions.  In patients with severe disease that is difficult to control with non-narcotic medication and other treatments, they may be considered on a longer term basis with careful monitoring.  These are generally considered more potent analgesics with higher risk for dependence and abuse, but patients with severe pain related to HS may require them to achieve adequate pain control.  It is not safe to take these medications if you also take benzodiazepines (Xanax, Ativan, valium) due to similar side effects, especially as they affect breathing.

While dermatologists and surgeons may use these drugs for a short period of time, in many instances they are managed by a single provider such as a general practitioner or pain specialist.  Pain contracts are often signed between patients and providers to help monitor amounts of these medications that patients receive.  The primary purpose of these agreements is to help physicians monitor safety and understand the needs of the patients they are treating so that they know how to safely increase and decrease a patient’s dose over time to control pain well and prevent withdrawal symptoms or complications.   It also allows the discussion about the risks and potential benefits of the medication, and to set goals with the use of opioids.  Should goals not be met, then it is safer to wean and discontinue the medication if it is not providing benefit. Caution must be used when driving or operating machinery.

Tramadol is a weak opioid that may be prescribed at doses of 50-100mg every 6 hour to control pain as needed.

Hydrocodone and oxycodone may be used at doses of 5-10 mg every 6 hours for acute pain or following procedures, and are often combined with acetaminophen or NSAIDs.  Extended release forms of these drugs are sometimes used when patients require treatment for extended periods of time.

Other opiate pain medications may be prescribed based on individual patient needs.

Pain following surgery:

You can consider discussing a “multi-modal approach” to post-surgical pain with your surgeon and anesthesiologist.  What this means is aggressively treating pain with many of the previously listed non-narcotic medications (acetaminophen, gabapentin/pregabalin, and NSAIDs for example) in addition to other medications such as ketamine and lidocaine infusions that we can only give in the operating room.  Studies in many types of surgeries show that this approach is not only beneficial to help control your surgical pain immediately after surgery (and decrease the amount of narcotic medication needed), but also to help decrease the chance of having or increasing chronic pain.

Non-medicinal approaches:

Cognitive behavioral therapy, which does not involve the use of any medications, is focused on developing mental strategies for coping with and reducing perception of pain.  Many pain clinics have pain trained psychologists that can work with you with cognitive behavioral therapy and other coping mechanisms, and is a great option for many patients if available.

 

References
1.       Horváth B, Janse IC, Sibbald GR.  Pain management in patients with hidradenitis suppurativa. J Am Acad Dermatol. 2015 Nov;73(5 Suppl 1):S47-51
2.       Scheinfeld N. Treatment of hidradenitis suppurativa associated pain with nonsteroidal anti-inflammatory drugs, acetaminophen, celecoxib, gabapentin, pegabalin, duloxetine, and venlafaxine. Dermatol Online J. 2013;19:20616.

3.       Scheinfeld N. Topical treatments of skin pain: a general review with a focus on hidradenitis suppurativa with topical agents.  Dermatol Online J. 2014;20(7).

4.       Smith HS, Chao JD, Teitelbaum J. Painful hidradenitis suppurativa.  Clin J Pain. 2010;26:435-444.

5.       Enamandram M, Rathmell JP, Kimball AB.  Chronic pain management in dermatology: pharmacotherapy and therapeutic monitoring with opioid analgesia.  J Am Acad Dermatol. 2015 Oct;73(4):575-82; quiz 583-4.

6.       Enamandram M, Rathmell JP, Kimball AB.  Chronic pain management in dermatology: a guide to assessment and nonopioid pharmacotherapy.  J Am Acad Dermatol. 2015 Oct;73(4):563-73; quiz 573-4.

7.       Glass JS, Hardy CL, Meeks NM, Carroll BT.  Acute pain management in dermatology: risk assessment and treatment.  J Am Acad Dermatol. 2015 Oct;73(4):543-60; quiz 561-2.

8.       Meeks NM, Glass JS, Carroll BT.  Acute pain management in dermatology: mechanisms and pathways.  Hautarzt. 2013 Jun;64(6):435-42.