Consensus on the treatment of hidradenitis suppurativa - Brazilian Society of Dermatology*

Hidradenitis suppurativa is a chronic immune mediated disease of universal distribution that causes great damage to the quality of life of the affected individual, whose prevalence is estimated at 0.41% in the Brazilian population. The objective of this work was update on physiopathogenesis, diagnosis and classification of hidradenitis suppurativa and to establish therapeutic recommendations in the Brazilian reality. It was organized as a work group composed of eight dermatologists from several institutions of the country with experience in the treatment of hidradenitis suppurativa and carried out review on the topic. Recommendations were elaborated and voted by modified Delphi system and statistical analysis of the results was performed. The Brazilian consensus on the clinical approach of hidradenitis suppurativa had the support of the Brazilian Society of Dermatology.

# Introduction
Hidradenitis suppurativa (HS) is a universally distributed chronic inflammatory condition that leads to a great impairment in the life of those affected, with an estimated prevalence of 1% to 4% of the population. [bib_ref] Actualizacion en hidradenitis supurativa (I): epidemiologia, aspectos clinicos y definicion de severidad..., Martorell [/bib_ref] In Brazil, the prevalence is 0.41%, with no difference between the many regions in the country, being more prevalent among adolescents (0.57%) and adults (0.47%) than in children (less than 0.03%), according to a study based on a telephone survey with more than 17,000 people from 87 municipalities. 2

## Objective of the consensus
The objective of this consensus is to inform the physician about HS and provide recommendations on its treatment according to the Brazilian context. It is not a systematic review but a docu-ment that integrates the newest immune-inflammatory concepts, taking into consideration the classification, investigation and treatment based in evidence from the literature, guided by international guidelines and validated by Brazilian specialists with the modified "Delphi" system. [bib_ref] Consensus on the management of patients with psoriatic arthritis in a dermatology..., Gisondi [/bib_ref] The differences in practice between men, women, adults and children are also one talking point.
To prepare this consensus, a work group made by eight der- s Recommendations based on evidence were established, arranged into a poll system (Survey Monkey  ) and forwarded to the specialists. For the topics "general measures" and "topical treatments" and for the topic "immunobiologics", polls through the modified Delphi system (RAND/UCLA) were conducted, where agreement was indicated with the statements (1=totally agree; 2=partially agree; 3=do not agree or disagree; 4=partially disagree;
5=totally disagree). The recommendations that achieved more than 75% of agreement among the specialists were included. The remaining were re-evaluated, re-discussed and re-posted for voting for the second time. Data obtained were analyzed statistically. [bib_ref] Consensus on the management of patients with psoriatic arthritis in a dermatology..., Gisondi [/bib_ref] For the topic "systemic treatments", a ranking according to the order of preference among the drugs that should be used for the treatment of HS was asked of the specialists. To verify differences in the specialists'
preferences, the Friedman test was used, and the significance level adopted was of 5%. The sample was obtained by nomination and subjected to the randomness test, which resulted in the non-rejection of randomness, with a significance level of 5%. [bib_ref] The use of ranks to avoid the assumption of normality implicit in..., Friedman [/bib_ref] Data were arranged into tables with levels of evidence (Cen- with the formation of abscesses and fistulas. Sex steroids seem to influence the course of the disease with onset after puberty, female predominance and perimenstrual exacerbation; however, their contribution to the pathogenesis is still unclear. [bib_ref] Actualizacion en hidradenitis supurativa (I): epidemiologia, aspectos clinicos y definicion de severidad..., Martorell [/bib_ref] [bib_ref] Update on hidradenitis suppurativa: connecting the tracts, Gill [/bib_ref] [bib_ref] Pathophysiology of hidradenitis suppurativa : An update, Prens [/bib_ref] COMORBIDITIES Hidradenitis suppurativa can be associated to many diseases, such as follicular occlusion syndrome (acne conglobata, dissecting cellulitis and pilonidal sinus); auto-inflammatory diseases such as SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis), The total value is stratified as mild (score of 3 or less), moderate (score of 4 to 10) and severe (score of 11 or more). 23
[formula] PASH [/formula]

## Hidradenitis suppurativa score (hiscr)
This scale was developed with the purpose of being a pa- In view of these considerations, weight loss is recommended in the approach of the patient with HS, with or without disease activity. [bib_ref] T helper 17 cell/regulatory T-cell imbalance in hidradenitis suppurativa/acne inversa: the link..., Melnik [/bib_ref] [bib_ref] Resolution of hidradenitis suppurativa after weight loss by dietary measures, especially on..., Boer [/bib_ref] [bib_ref] Rapid resolution of hidradenitis suppurativa after bariatric surgical intervention, Thomas [/bib_ref] [bib_ref] The influence of body weight on the prevalence and severity of hidradenitis..., Kromann [/bib_ref] Management of pruritus It is not common to ask about pruritus when seeing patients with HS. However, great part of the patients complain of pruritus that can even impair sleep and, consequently, the quality of life.
Studies demonstrate that pruritus, as erythema and local pain are considered prodromal symptoms for flares. Pruritus control is recommended with or without disease activity, with the primary goal of improving the quality of life of these patients. [bib_ref] Assessing Pruritus in Hidradenitis Suppurativa: A Cross-Sectional Study, Vossen [/bib_ref] 

## Friction
Studies demonstrated the impact that friction has on the stability and distortions of the hair follicle even before the formation of the follicular plug. The predilection of HS to flexural areas is clear, as well as a higher prevalence in obese patients. Restricting the use of tight clothing and/or clothing that causes friction in the areas of predilection for HS lesions is recommended. [bib_ref] Should hidradenitis suppurativa be included in dermatoses showing koebnerization? Is it friction..., Boer [/bib_ref] [bib_ref] The Role of mechanical stress in hidradenitis suppurativa, Boer [/bib_ref] Local antiseptics It is known that HS is an inflammatory disease and when an infectious process occurs it is secondary. There is the hypothesis that follicular occlusion could be a site for bacterial colonization, triggering an exacerbated inflammatory reaction to the local microbiome.
Advice on adequate local hygiene should be given, although there is no need to exhaustively remove germs or to use soaps with high concentrations of chlorhexidine. [bib_ref] Combination of oral zinc gluconate and topical triclosan: An anti-inflammatory treatment modality..., Hessam [/bib_ref] 

## Topical treatments clindamycin
One percent clindamycin gel is the only topical antibiotic with randomized studies comparing its efficacy to the use of a systemic medication, tetracycline. There was no difference in efficacy after 3 months of treatment. During the use of topical clindamycin, superficial lesions (pustules, folliculitis) showed better responses when compared to deeper lesions (nodules and abscesses). In view of these considerations, the use of 1% clindamycin gel in HS lesions is recommended for Hurley stage I or in cases with superficial lesions during exacerbation periods. [bib_ref] Topical clindamycin versus systemic tetracycline in the treatment of hidradenitis suppurativa, Jemec [/bib_ref] [bib_ref] Management of hidradenitis suppurativa: a UK survey of current practice, Ingram [/bib_ref] [bib_ref] Clinical practice. Hidradenitis suppurativa, Jemec [/bib_ref] Fusidic acid The use of fusidic acid was evaluated through case reports and one prospective study where Hurley stage I patients were assessed. They were submitted to conservative therapy with fusidic acid, besides local antiseptics until the inflammatory nodules were under control, and more than 70% of cases achieved control. [bib_ref] Effective modified conservative tissue preserving protocol to treat stage I axillary hidradenitis..., Shirah [/bib_ref] Comparing with gentamicin and mupirocin, fusidic acid has a higher minimum inhibitory concentration in the deeper layers of the skin. In view of these considerations, the use of fusidic acid in HS lesions can be useful for Hurley stage I. [bib_ref] Effective modified conservative tissue preserving protocol to treat stage I axillary hidradenitis..., Shirah [/bib_ref] [bib_ref] Fusidic acid in dermatology: an updated review, Schofer [/bib_ref] Other topical antibiotics There are not enough studies to support the use of gentamicin or erythromycin in HS. Some studies evaluated the use of gentamicin for the postoperative period with the aim of assessing the rates of recurrence and local complications. A reduction in short-term complications was seen (8 weeks); however, there was no success in the long-term rates of recurrence.The use of gentamicin in HS lesions would only be indicated if the use of other topical antibiotics was not possible.

## Benzoyl peroxide associated to clindamycin
Topical treatment with 10% benzoyl peroxide gel associated to 1% clindamycin gel or lotion was compared to the topical treatment associated to Nd-Yag laser hair removal in a controlled, prospective study with 22 Hurley I to III patients. Progressive improvement in the activity of the disease was seen, more markedly during the 4 months of treatment, which was maintained in the post-treatment 2-month follow-up period. The improvement was of 72.7% on the side treated with laser and 22.9% on the control side, suggesting that topical treatments improve HS, although less than when associated to laser hair removal. There are no studies with benzoyl peroxide alone. [bib_ref] Prospective controlled clinical and histopathologic study of hidradenitis suppurativa treated with the..., Mahmoud [/bib_ref] Topical retinoid Some specialists suggest the use of adapalene, azelaic acid, antiseptics or other acne treatments can be beneficial; however, evidence is lacking to indicate such treatments. [bib_ref] Consensus on the management of patients with psoriatic arthritis in a dermatology..., Gisondi [/bib_ref] [bib_ref] Management of patients with hidradenitis suppurativa, Martorell [/bib_ref] [bib_ref] Interventions for hidradenitis suppurativa: a Cochrane systematic review incorporating GRADE assessment of..., Ingram [/bib_ref] Resorcinol cream Topical resorcinol was studied in a prospective study. Twelve patients with Hurley I or II HS were instructed to apply 15% resorcinol cream twice daily on the active HS lesions. In all patients, the use of resorcinol resulted in reduction of pain and reduction in the mean duration of painful abscesses. Topical resorcinol (m-dihydroxybenzene) is an exfoliant with keratolytic, antipruritic and antiseptic activity. It can be useful to shorten the mean duration of a painful nodule or abscess. [bib_ref] Consensus on the management of patients with psoriatic arthritis in a dermatology..., Gisondi [/bib_ref] [bib_ref] Resorcinol peels as a possible self-treatment of painful nodules in hidradenitis suppurativa, Boer [/bib_ref] There are still no controlled, randomized studies on its efficacy.

## Intralesional steroid

## Step 2
Systemic treatment Children younger than 12 years of age Studies show that 36% of HS cases occur before 20 years of age; this datum is controversial, ranging from less than 2% of cases before 11 years of age to 7.6% before 13 years. [bib_ref] Early-onset hidradenitis suppurativa, Palmer [/bib_ref] [bib_ref] Hidradenitis Suppurativa in prepubescent and pubescent children, Scheinfeld [/bib_ref] [bib_ref] Correlation of early onset hidradenitis suppurativa with stronger genetic susceptibility and more..., Deckers [/bib_ref] However, only studies with low levels of evidence are available for the treatment of HS in the pediatric age group.
The use of systemic antibiotics is based in clinical trials in adults. Different case series of HS in children identified oral erythromycin and clindamycin among the most commonly used antibiotics. Tetracyclines are not recommended in people younger than 10 years of age due to the risk of permanent changes in the color of the teeth. Rifampicin associated to clindamycin can be used in the pediatric group. [bib_ref] Hidradenitis suppurativa in children and adolescents: a review of treatment options, Mikkelsen [/bib_ref] Isotretinoin was also frequently described in these series, despite not being the first choice due to the limited effect described in adults. [bib_ref] Prepubertal onset of hidradenitis suppurativa in a girl: A case report and..., Stojkovic-Filipovic [/bib_ref] Regardless of the presence or absence of premature adrenarche in the endocrinological evaluation, antiandrogens such as finasteride (1 to 5mg/day) have been shown to be effective in refractory HS in children. [bib_ref] Hidradenitis suppurativa in the pediatric population, Liy-Wong [/bib_ref] [bib_ref] Finasteride for the treatment of hidradenitis suppurativa in children and adolescents, Randhawa [/bib_ref] Two case series (3 and 5 children)
showed efficacy and achievement of remission for variable periods of 5 to 24 months, with few adverse events. Due to the risk of feminization of the fetus, its use is recommended in cases refractory to topical and oral antibiotics, before considering biologic or surgical treatment. Finally, the use of botulinum toxin was reported with an initial satisfactory result but recurrence after 6 months. 66

## Women of childbearing age
Case series comparing women using antiandrogen medications (conjugated contraceptive with cyproterone; spironolactone; spironolactone and cyproterone; 29 cases) versus oral antibiotics (tetracyclines, trimethoprim/sulfamethoxazole; 23 cases) showed a higher response rate in the first group (55%) when compared to the second group (26%). [bib_ref] Current concepts in the management of hidradenitis suppurativa in children, Danby [/bib_ref] Antiandrogen strategy in women is an interesting option with level of evidence C and can be indicated for those who fail antibiotic treatments. The ideal antiandrogen regimen is controversial, with no differences in HS responses identified with ethynilestradiol combined with cyproterone or with norgestrel. [bib_ref] A double-blind crossover trial of cyproterone acetate in females with hidradenitis suppurativa, Mortimer [/bib_ref] Isotretinoin was evaluated in 7 different studies with levels of evidence B and C, and the collective of patients in these studies showed lack of efficacy in 64%. Despite the high percentage of responders in studies with acitretin, with levels of evidence B and C, it is not appropriate to women of childbearing age, and in this situation the choice of isotretinoin over acitretin is justified. [bib_ref] Systemic therapy with immunosuppressive agents and retinoids in hidradenitis suppurativa: a systematic..., Blok [/bib_ref] The use of systemic steroids is based in a study with hydrocortisone published in 1958. [bib_ref] Preliminar y studies of the effect of hydrocortisone on hidradenitis suppurativa, Danto [/bib_ref] The disease responds to high daily doses of prednisone 0.5-0.7mg/kg/day, with recurrence after dose reduction. Therefore, systemic steroids are indicated essentially for flares, for short periods of time. However, a publication of a small case series shows that low daily doses for limited periods can be useful for refractory cases, associated to other medications.
Metformin was studied in a case series with 25 individuals (22 of those were females) with a previous history of antibiotic use and 11 of them using isotretinoin. In doses of up to 1.5g/day, 19 of these patients showed responses (DLQI and/or Sartorius) in 12 to 24 weeks. [bib_ref] Metformin for the treatment of hidradenitis suppurativa: A little help along the..., Verdolini [/bib_ref] Zinc gluconate is an option for the maintenance treatment in Hurley stages I and II, in a 90 mg dose divided into three doses.
The possible impairment in iron and copper absorption and gastrointestinal bleeding can limit its long-term use. [bib_ref] Consensus on the management of patients with psoriatic arthritis in a dermatology..., Gisondi [/bib_ref] [bib_ref] Hidradenitis suppurativa and zinc: a new therapeutic approach. A pilot study, Brocard [/bib_ref] Dapsone was evaluated in 3 different studies with level of evidence C, demonstrating a significant response in 35%, moderate in 21% and absent in 44%, suggesting its use in patients who fail first-or second-line systemic treamtents. [bib_ref] Systemic therapy with immunosuppressive agents and retinoids in hidradenitis suppurativa: a systematic..., Blok [/bib_ref] Data for methotrexate and ciclosporin are not robust and these drugs should be considered as third-line of association for long-term inflammation control.

## Non-childbearing age women and men
Tetracycline 500mg twice daily led to a reduction of approximately 30% in disease severity but showed no benefits when compared to 1% topical clindamycin. [bib_ref] Topical clindamycin versus systemic tetracycline in the treatment of hidradenitis suppurativa, Jemec [/bib_ref] The association of clindamycin and rifampicin was tested in 3 case series studies with the 300mg dose of clindamycin and 600mg of rifampicin daily for 10 weeks, demonstrating global, pain and Sartorius score improvement. [bib_ref] Combination therapy with clindamycin and rifampicin for hidradenitis suppurativa: a series of..., Gener [/bib_ref] [bib_ref] The effect of combined treatment with oral clindamycin and oral rifampicin in..., Mendonca [/bib_ref] A recent study demonstrated that the association of clindamycin (600 to 1800mg, according to the weight) and ofloxacin Sixty-five patients were treated and 33.8% had complete response and 24.6% partial response, regardless on the initial Hurley stage. [bib_ref] Oral ofloxacin and clindamycin as an alternative to the classic rifampicin clindamycin..., Delaunay [/bib_ref] The combination of minocycline 100mg daily for 6 months and colchicine 0.5mg twice daily for 9 months was also reported in a pilot study with 20 patients. More than 90% of patients had a PGA (Physician Global Assessment) between good and excellent for up to 9 months of observation. [bib_ref] Hidradenitis suppurativa treated with tetracycline in combination with colchicin: a prospective series..., Armyra [/bib_ref] There are reports of improvement in retrospective studies with few patients with dapsone in doses between 25-200mg/day for at least 3 months, with fast recurrence after discontinuation. [bib_ref] Dapsone therapy for hidradenitis suppurativa: a series of 24 patients, Yazdanyar [/bib_ref] [bib_ref] Hidradenitis suppurativa treated with dapsone: a case series of five patients, Kaur [/bib_ref] The use of isotretinoin for the treatment of HS is questio- Crohn's disease. [bib_ref] Review of the current immunologic therapies for Hidradenitis suppurativa, Shanmugam [/bib_ref] The first reported case of hidradenitis suppurati-

## Adalimumab
Adalimumab is a fully humanized monoclonal antibody proteins that target soluble and transmembrane TNF-alpha. [bib_ref] Review of the current immunologic therapies for Hidradenitis suppurativa, Shanmugam [/bib_ref] Adalimumab is the only approved medication that is indicated for the treatment of hidradenitis suppurativa.Adalimumab was also effective for improving the quality of life of patients with HS. HiSCR rates were maintained long-term and the safety profile in moderate to severe HS patients was similar to that reported for the drug in other indications. [bib_ref] Two Phase 3 Trials of Adalimumab for Hidradenitis Suppurativa, Kimball [/bib_ref] A recent study demonstrated that the ratio of patients with reduced infectious events related to the treatment was higher when compared to placebo.The need for higher induction and maintenance doses to achieve better disease control in comparison to the doses used in rheumatoid arthritis, psoriasis and Crohn's disease is related to a higher inflammatory burden of hidradenitis suppurativa in relation to those diseases. [bib_ref] Management of patients with hidradenitis suppurativa, Martorell [/bib_ref] Adalimumab dosing for the treatment of hidradenitis suppurativa was established with the PIONEER II study and is of 160mg at day 1, 80mg at day 14 and 40mg weekly from day 29.
The treatment is indicated for a period determined by the treating physician. Once the inflammation is under control, the areas with residual activity or scarring can be excised. Treatment maintenance with adalimumab contributes to reduce recurrences. 111

## Infliximab
It is a chimeric antibody formed by human and murine proteins that targets soluble and transmembrane TNF-alpha. [bib_ref] Review of the current immunologic therapies for Hidradenitis suppurativa, Shanmugam [/bib_ref] Manifestations known as paradoxical can subsequently develop in patients with conditions being treated by biologics and changing the biologic drug or associating it to other treatments might be necessary to fully control the clinical manifestations.

## Recommendations for the treatment of hidradenitis

## Suppurativa according to the level of evidence, grade

## Of recommendation and degree of agreement among

## Specialists
The topics discussed and voted by the experts are indicated in charts 2 and 3, according to level of evidence and degree of recommendation.
It was a consensus among the specialists that measures such as weight loss, smoking cessation, hair removal and local antisepsis should be recommended, with a concordance of 100%.
Topical treatment for isolated and superficial lesions is a possibility, and topical 1% clindamycin has the best evidence and is incorporated in international guidelines as first line. The use of fusidic acid and 15% resorcinol is justified in the literature but there is no evidence of the benefit of the use of other topical treatment mo-dalities like benzoyl peroxide and retinoids. The 75% concordance among the specialists was for the use of clindamycin, fusidic acid and resorcinol. It is important to emphasize that HS lesions have a self-limited course.
The rational use of topical antibiotic is a growing concern due to the risk of bacterial resistance. [bib_ref] A randomized, double-blind comparison of a clindamycin phosphate/benzoyl peroxide gel formulation and..., Cunliffe [/bib_ref] [bib_ref] Addressing resistance to antibiotics in systematic reviews of antibiotic interventions, Leibovici [/bib_ref] [bib_ref] Patterns of antimicrobial resistance in lesions of hidradenitis suppurativa, Fischer [/bib_ref] The recommendation is to use it for a limited time and avoid repeating it. The association with other topicals such as benzoyl peroxide or replacement with resorcinol are a good strategy to minimize the risk.
Regarding intralesional therapies, the concordance among the specialists was of 100% for the use of triamcinolone acetonide in the case of localized nodules and abscesses with inflammatory signs.
Sulfa and tetracycline substances were indicated as first choice. Among those, the medications trimethoprim/sulfamethoxazole and tetracycline were the most voted. To confirm if there was any difference in the specialists' preference regarding the type of medication to be used, the Friedman test was used and the level of significance adopted was of 5%. The results demonstrated that preferences are not similar among specialists.
Therefore, the concordance regarding the use of antibiotics such as sulfas and tetracyclines in the initial approach of moderate to severe HS was of 100% among the specialists.
There must be caution with the use of rifampicin. [bib_ref] Development of resistance to Mycobacterium tuberculosis is manageable in hidradenitis suppurativa. Response..., Albrecht [/bib_ref] In Brazil and in countries where there is a high prevalence of tuberculosis and Hansen's disease, its use should be discussed with local epidemiological surveillance authorities. These infectious diseases should be screened before starting the treatment. Rifampicin is a first-line drug for the treatment of tuberculosis. The incidence of tuberculosis cases resistant to polychemotherapy has increased worldwide and particularly in countries where the disease has a high prevalence, according to an alert from the World Health Organization (WHO).
The association of other antibiotic regimens such as clindamycin and ofloxacin can have similar efficacy. [bib_ref] Oral ofloxacin and clindamycin as an alternative to the classic rifampicin clindamycin..., Delaunay [/bib_ref] Systemic treatment with clindamycin plus ofloxacin can be indicated in cases of moderate to severe HS as second-line antibiotic therapy. There was an 87.5% concordance among specialists for this statement.
The course of antibiotic therapy should be long, for at least 10 to 12 weeks and with optimized doses.
It can be associated with or followed by other medications with an anti-inflammatory or antiandrogen effect. Other immunomodulators such as dapsone, for example, can be considered as It is a simple technique that allows for speedy recovery and can be performed in the outpatient setting. [bib_ref] Deroofing: a tissue-saving surgical technique for the treatment of mild to moderate..., Van Der Zee [/bib_ref] The risk of recurrence is higher with partial simple excision than with wide excision. [bib_ref] Surgical approach to extensive hidradenitis suppurativa, Buyukasik [/bib_ref] 

## Final considerations
HS is considered to be one of the diseases that impairs the quality of life of affected individuals the most. Current knowledge on its ethiopathogenesis has grown considerably and has confirmed its immune-mediated background. Treatment of the disease in early phases where there is pre-clinical inflammation without structural damage can avoid or reduce the devastating progression to fistulas and scarring, which will require surgical treatment. Thus, early diagnosis, interventions on risk factors such as treating obesity, metabolic and hormonal disturbances and smoking cessation measures when the first signs arise are factors that can interfere with the course and severity of the disease.The inflammation phase that precedes tissue destruction represents the window of opportunity to adequately approach the disease. Treatment with antibiotics and immunosuppressants can contribute to a better systemic control of the inflammation, its repercussion in other organs and its complications. [bib_ref] Management of patients with hidradenitis suppurativa, Martorell [/bib_ref] HS patients should be screened annually due to the high prevalence of associated diseases and the higher risk of cardiovascular disease. Obesity, diabetes, hypertension, metabolic syndrome, besides inflammatory bowel disease, joint disorders, anxiety and depression, smoking and alcoholism are important conditions that should be investigated.Clinical and surgical care should be constant since in acute phases, drainage and minor excisions can be necessary and in ad-Consensus on the treatment of hidradenitis suppurativa -Brazilian Society of Dermatology vanced phases, established fistulas with frequent suppuration and scarring, that are considered static lesions, require wide excisions. In this sense, multidisciplinary care should be encouraged. [bib_ref] Longitudinal observational study of hidradenitis suppurativa: impact of surgical intervention with adjunctive..., Shanmugam [/bib_ref] The use of biologics drugs was shown to be effective and safe in HS, indicated for moderate to severe cases that failed conventional treatment. An European consensus, based on a systematic review of the literature and voted by the Delphi system among experts, suggests that the immunobiological treatment should be maintained for at least one year if the patient is a good responder, but if there is no improvement of at least 25% in HiSCR in the first twelve weeks, this should be reconsidered. [bib_ref] Hidradenitis suppurativa/acne inversa: A practical framework for treatment optimization systematic review and..., Zouboulis [/bib_ref] The aim of this consensus is to guide the dermatologist in the approach of the patients with HS in the Brazilian reality, and the authors are open to reevaluation and updating, besides the evaluation of its impact in the dermatology Community . q
[fig] 200: to 400mg) for a mean observation period of 4.3 months led to comparable results to the association of rifampicin and clindamycin. [/fig]