Hidradenitis Supprurativa (HS) is a painful chronic follicular disease. Few papers have addressed
pain control for this debilitating condition. Possible topical agents include
tricyclic antidepressants,
opioids,
anticonvulsants,
NSAIDs,
NMDA receptor antagonists,
local anesthetics and other agents. The first line agents for the topical treatment of the cutaneous
pain of HS are diclonefac gel 1% and liposomal
xylocaine 4% and 5% cream or 5%
ointment. The chief advantage of topical
xylocaine is that is quick acting i.e. immediate however with a limited duration of effect 1-2 hours. The use of topical
ketamine, which blocks
n-methyl-D-aspartate receptors in a non-competitive fashion, might be a useful tool for the treatment of HS
pain. Topical
doxepin, which available in a 5% commercially preparation (Zonalon®) , makes patients drowsy and is not useful for controlling the
pain of HS .
Doxepin is available in a 3% or 3.3% concentration (which causes less drowsiness) from compounding pharmacies and can be used in compounded
analgesic preparations with positive effect. Topical
doxepin is preferred over use of topical
amitriptyline because topical
doxepin is more effective. Nevertheless, topical
amitriptyline increase of the tactile and mechanical nociceptive thresholds and can be used for topical
pain control in compound mixture of
analgesics .
Gabapentin and pregablin can also be used compounded with other agents in topical
analgesic preparations with positive topical
anesthetic effect.
Capsaicin is not useful for topical treatment of the
pain of HS. Sometimes compounded of
anesthetics medications such as
ketamine 10%,
bupivacaine 1%,
diclofenac 3%,
doxepin 3% or 3.3%, and
gabapentin 6% can extend the duration of effect so that medication only needs to be used 2 or 3 times a day. Still in my experience the easiest to get and most patient requested agent is topical diclonefac 1% gel.