ORIGINAL ARTICLE

Intralesional triamcinolone for flares

of hidradenitis suppurativa (HS):
A case series
Peter Theut Riis, MD,a Jurr Boer, MD, PhD,b Errol P. Prens, MD, PhD,c Ditte M. L. Saunte, MD, PhD,a
Inge E. Deckers, MD, PhD,c Lennart Emtestam, MD, PhD,d Karin Sartorius, MD, PhD,e
and Gregor B. E. Jemec, MD, DMSca
Roskilde, Denmark; Deventer and Rotterdam, The Netherlands; and Stockholm, Sweden

Background: Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the hair follicle. Standard
practice of managing acute flares with corticosteroid injection lacks scientific evidence.

Objective: We sought to assess the outcomes of routine treatment using intralesional triamcinolone
(triamcinolone acetonide 10 mg/mL) in the management of acute flares in HS.

Methods: This was a prospective case series evaluating the effect of intralesional corticosteroids for
alleviation of acute flares in HS. Physician- and patient-reported outcomes were noted.

Results: Significant reductions in physician-assessed erythema (median score from 2-1, P \.0001), edema
(median score from 2-1, P \ .0001), suppuration (median score from 2-1, P \ .0001), and size (median
score from 3-1, P \ .0001) was demonstrated at follow-up. A significant difference in patient-reported
pain visual analog scale scores occurred after 1 day (from 5.5-2.3, P \.005) and from day 1 to day 2 (from
2.3-1.4, P \ .002).

Limitations: Small study size, open single-arm design, and short follow-up time are the limitations of this
study.

Conclusion: Intralesional injection of corticosteroids is perceived as beneficial by physicians and patients

in the management of HS flares by reducing pain after 1 day and signs of inflammation approximately
7 days later. ( J Am Acad Dermatol http://dx.doi.org/10.1016/j.jaad.2016.06.049.)

Key words: acne inversa; corticosteroids; hidradenitis suppurativa; inflammation; intralesional; skin
disease; triamcinolone acetonide.

From the Departments of Dermatology at Roskilde Hospital,a
Deventer Hospital,b and Erasmus University Medical Center,
Rotterdamc; Section of Dermatology and Venereology, Depart-
ment of Medicine, Huddinge at Karolinska Institutet, Stock-
holmd; and Department of Dermatology, Stockholm South
General Hospital.e
Drs Boer and Prens contributed equally.
Funding sources: None.
Disclosure: Dr Boer serves on the advisory board of AbbVie. Dr
Saunte was paid as a consultant for advisory board meetings
by AbbVie and as a speaker for Bayer, Galderma, Astellas, and
Leo Pharma. She also received reimbursement of travel
expenses from Galderma, Pfizer, AbbVie, and Desitin. Dr Prens
received honoraria from AbbVie, Amgen, Celgene, Janssen,
Galderma, Novartis, and Pfizer for participation as a
speaker and advisory board member, and received
investigator-initiated grants (paid to Erasmus University Med-
ical Center) from AbbVie, AstraZeneca, Janssen, and Pfizer. Dr
Emtestam was paid as a consultant by AbbVie, as a consultant
for advisory board meetings by AbbVie, and as a speaker for
Novartis and AbbVie. Dr Sartorius received honoraria from
AbbVie (consultant/faculty meeting) and Leo Pharma (inves-
tigator/faculty meeting), and honoraria paid to the department
by AbbVie. Dr Jemec received honoraria from AbbVie, MSD,
and Pfizer for participation on advisory boards, and grants from
AbbVie, Actelion, Janssen-Cilag, Leo Pharma, Novartis, and
Regeneron for participation as an investigator. He received
speaker honoraria from AbbVie, Galderma, Leo Pharma, and
MSD. He has furthermore received unrestricted research grants
from AbbVie and Leo Pharma. Drs Riis and Deckers have no
conflicts of interest to declare.
Accepted for publication June 25, 2016.
Reprint requests: Peter Theut Riis, MD, Department of
Dermatology, Roskilde Hospital, Køgevej 7-13, 4000 Roskilde,
Denmark. E-mail: pmik@regionsjaelland.dk.
Published online September 28, 2016.
0190-9622/$36.00
Ó 2016 by the American Academy of Dermatology, Inc.
http://dx.doi.org/10.1016/j.jaad.2016.06.049

1
2 Riis et al J AM ACAD DERMATOL
n 2016

Hidradenitis suppurativa (HS) has an estimated
prevalence of 1% to 2%,1,2 with a higher frequency in
the overweight population (body mass index [30),
in females,1 and in smokers.3 Objectively, the disease
presents with inflamed nodules, boils, sinus tracts/
tunnels, and tombstone-comedos in the intertrigi-
nous areas such as the axilla, groin, perineal areas,
and under the breasts.1
Rupture of the outer root
sheaths and an intense CAPSULE SUMMARY
inflammatory response are
Although recommended in the literature,
d
become a mainstay in the management of flares. Its
mention in guidelines is, however, based on expert
consensus and, to our knowledge, no actual
assessment of its efficacy has been provided. The
proposed mechanism of action is through activation
of the glucocorticoid receptor, blocking synthesis of
leukotrienes and reducing the production of
proinflammatory cytokines
such as interleukin-1. In
addition, triamcinolone is
also thought to inhibit cyto-
toxic T-cell activation.17

considered important patho-

1 the effect of routine intralesional
genic events in HS.
corticosteroids has not been assessed
Clinically, flares of painful METHODS
systematically.
nodules are a hallmark of This was a prospective
HS. These nodules interfere This study suggests that intralesional
d
multicenter study of intrale-
with everyday life, reducing corticosteroids may be useful for acute sional injections (triamcino-
not only quality of life,4,5 but flare management. lone 10 mg/mL) into inflamed
also causing missed days Routine intralesional treatment with
d lesions associated with HS
from work.5,6 Nodules may triamcinolone reduces patient-reported flares. Patients treated routi-
develop into abscesses, pain significantly within 1 day, and nely with intralesional injec-
further complicating the physician-assessed severity within tions were included from the
patient’s situation by addi- 7 days. Department of Dermatology,
tional pain and malodourous Roskilde Hospital, Roskilde,
discharge. Denmark (n = 10); Depart-
The aim of medical treatment is to reduce the ment of Dermatology, Erasmus University Medical
incidence of inflamed nodules, and treatment usu- Center, Rotterdam, The Netherlands (n = 19); Section
ally requires weeks to months to be effective.7-13 of Dermatology and Venereology, Department of
Studies of patient treatment have indicated that these Medicine, Huddinge at Karolinska Institute,
flares are often treated with surgical procedures Stockholm, Sweden (n = 3); and Department
appropriate for treatment of abscesses such as of Dermatology, Stockholm South General Hospital,
incision and drainage. Although this method is Stockholm, Sweden (n = 4). Adult, nonpregnant
suitable for the management of a cystic lesion such consecutive patients presenting with acute HS-related
as an abscess, it is not appropriate for the manage- nodules or abscesses were included. The nodules or
ment of a solid process such as the HS nodule. abscesses were injected with triamcinolone (10 mg/
Incision and attempted drainage of nodules is mL). The volume injected was dependent on the size of
therefore usually ineffective in relieving pain, and the lesion and decided solely by the treating clinician.
appears associated with a recurrence rate of 100% Patients who returned for follow-up a week later were
and increased scarring.14 Therefore, incision and included.
drainage is generally discouraged unless fluctuant In addition, the involved clinicians were asked to
abscesses have developed.15 An unmet need for evaluate 3 signs of inflammation: redness, edema,
adequate management of acute flares therefore and suppuration. Each aspect was evaluated on a
exists. 5-point (0-4) anchored rating scale: 0 represented
Intralesional injection of corticosteroid has been normal-appearing skin in all aspects and 4
suggested16 to fill this therapeutic gap, and has represented dark-red erythema, pronounced edema,

Table I. Median, mode, and physician-assessed Table II. Volume of triamcinolone as predictor for
parameters at day 0 (preinjection) and at follow-up visual analog scale scores difference, adjusted for
size of the lesion
Physician-assessed parameters Day 0 Follow-up
Redness (mode) 2 (2) 1 (1)* VAS score change Beta P value
Suppuration (mode) 2 (2) 1 (1)* Day 0-7 1.159 .099
Size (mode) 3 (3) 1 (1)* Day 0-1 3.345 .447
Edema (mode) 2 (2) 1 (1)* Day 1-2 2.693 .202

*P = .001. VAS, Visual analog scale.

J AM ACAD DERMATOL Riis et al 3
VOLUME jj, NUMBER j

Fig 1. Mean visual analog scale (VAS ) scores and SD for days 0 through 7. *Days with a
significant difference from the day before.

Table III. Absolute visual analog scale scores for

pain over 1 week
P value (difference Relative mean
from the score compared
VAS scores Mean (SD) day before) with day 0
Day 0 5.5 (2.3) 100
Day 1 2.3 (1.7) .005 42%
Day 2 1.4 (1.5) .002 25%
Day 3 1.1 (1.4) NS 20%
Day 4 0.9 (1.4) NS 16%
Day 5 0.8 (1.5) NS 15%
Day 6 0.8 (1.5) NS 15%
Day 7 1.1 (1.8) NS 20%

NS, Not significant; VAS, visual analog scale.

Relative mean scores are also provided as relative to day 0.

and massive suppuration. The size of each lesion was

divided into categories of less than 0.5 cm, 0.5 to
1 cm, 1 to 1.5 cm, and 1.5 to 2 cm. Nodules or
abscesses greater than 2 cm were not included to
create a more homogenous group of lesions. The
physician-evaluated parameters were recorded
before injection and at the follow-up visit,
approximately 7 days later.
Patients were asked to evaluate pain on a visual
analog scale (VAS) scale from 0 to 10 with 0 repre-
senting no pain and 10 representing the worst pain
imaginable. The patients evaluated the treated lesion
before injection and each day (at approximately the
same hour each day) until follow-up to track day-to-
day changes.
Statistics
Descriptive data are reported. Means and SD were
calculated for scaled data. Medians and mode were
Fig 2. Hidradenitis suppurativa, preinjection, day 0.
calculated for ordinal data. Wilcoxon signed-rank
test was used to test for differences between day
0 (preinjection) and follow-up (day 6-10) scores
for each of the physician-assessed parameters.
Wilcoxon signed-rank test was used to determine
statistical differences in VAS scores between day
0 and day 1, and between day 0 and follow-up. We
tested for significant differences in VAS scores
between day 1 and day 2, and between day 2 and
day 3. Multiple linear regression examined the
correlation between the volume of triamcinolone
injected and the changes in VAS scores.
4 Riis et al
Fig 3. Hidradenitis suppurativa, postinjection, day 7.
Statistics were performed in SPSS 23.0 (IBM Corp,
Armonk, NY). A P value less than .05 was considered
significant.
RESULTS
A total of 36 patients presenting with acute
HS-related nodules or abscesses were included; 3
patients failed to show up for follow-up evaluation
and were excluded from further analysis. The
nodules or abscesses were injected with a mean of
0.75 mL triamcinolone 10 mg/mL (range 0.2-2.0 mL).
We found a significant difference in redness, size,
edema, and suppuration from preinjection to
follow-up (P \ .0001) (Table I). Changes in VAS
scores did not correlate with the volume of
triamcinolone injected, in a linear regression model,
adjusting for size of the lesion (Table II).
Patients reported a mean pain VAS score of 5.5
before treatment and 1.11 at the follow-up after a
mean of 6.9 days (SD 1.4) (Fig 1). A significant
difference in self-reported pain from day 0 (preinjec-
tion) to day 1, and from day 1 to day 2 was found
with a trend toward a difference between day 2 and
day 3 as well. The day-to-day reduction in the pain
score was greater than 30% for the first 2 days after
injection (Table III). See Figs 2 and 3 for comparison
of lesion before injection and at follow-up 7 days
later.
DISCUSSION
Many traditional treatments have been introduced
without the scientific evidence required today. The
use of intralesional corticosteroid in the treatment of
J AM ACAD DERMATOL
n 2016
HS was one such treatment. We examined the
efficacy of this treatment in an international multi-
centered audit and found a significant reduction in
physician-assessed edema, redness, and suppuration
after a mean of 6.9 days.
Patients correspondingly reported a significant
pain reduction of 3.2 in mean VAS scores 1 day
after treatment. The minimum clinical significant
difference in VAS scores are considered 0.9 to
1.3.18,19
This suggests that injection of triamcinolone into
inflamed nodules and abscesses of patients with HS
is beneficial in the short-term management of disease
flares, and may be taken to support the use of this
routine procedure.
Acute or short-term management of HS flares is
poorly described. The use of self-administered
topical resorcinol 15% cream has been suggested
for symptom and flare control in an open case
series.13 In this series of 12 patients, resorcinol
reduced VAS 10-point pain scores from 7.2 to 2.4
within 2 days of treatment.13 Comparatively this
audit found a reduction in VAS scores from 5.5 to
2.3 after just 1 day.
During flares, acute pain is the major symptom.20
Pain is the biggest contributor to patient disutility as
measured by EuroQol 5 dimensions 3 levels,4 a
disutility score designed to measure the adverse
and harmful effect on daily utility of any disease,4,21
and reduced quality of life as measured by
Dermatologic Life Quality Index.22
The lack of correlation between amount of
triamcinolone (volume of 10 mg/mL solution)
injected and the change of VAS scores has major
practical implications. It may suggest that the amount
of triamcinolone injected could be reduced without
sacrificing effect. It also exposes the weakness of the
audit approach as the changes may equally be
interpreted to reflect natural fluctuation of disease
severity or a response to drainage after the injection
procedure rather than the drug. The lack of a control
group is a weakness of the study, but it is not possible
to provide because of the nature of the audit type
study.
Within the limitations of the audit it is, however,
suggested that the routine use of intralesional
corticosteroid injections for the short-term
control of HS flares consisting of inflamed lesions is
useful.
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