Treatment of Hidradenitis Supprurativa Associated Pain with Nonsteroidal Anti-Inflammatory Drugs, Acetaminophen, Celecoxib, Gabapentin, Pegabalin, Duloxetine, and Venlafaxine

Abstract

Hidradenitis Supprurativa is a painful dermatological condition. Although the pain of HS has unique aspects, the pain of HS pain shares common elements with essential pain, fibromyalgia, and pure neuropathic pain syndromes. Futhermore, depression plays an important role in the pain of HS. This paper reviews the potential for use of nonsteroidal anti-inflammatory drug (NSAIDS), acetaminophen, celecoxib, gabpentin, pregabalin, and the serotonin and norepinephrine reuptake inhibitors (SNRIs), duloxetine and venlafaxine, for treating HS related pain. No studies exist for pain control in HS. Initially, the pain of HS is treated medically e.g. oral rifampin and clindamycin or adalimumab to decrease inflammation, but an analysis of pain medications to treat the pain of HS merits its own discussion and treatment algorithm. First-line HS pain treatments include: topical analgesics and oral NSAIDs, such as celecoxib (Celebrex®), and acetaminophen. If these are inadequate, which is common, the less expensive gabapentin (Neurontin®) 400-1200 mg TID or the more expensive (Lyrica®) pregabalin 50-100mg BID can be added for synergistic effect. In my experience, HS patients prefer pregabalin, which induces less drowiness than gabapentin. If these combinations are inadequate, an SNRI can be added. Of SNRIs, duloxetine (Cymbalta®) 30-120 mg, given QD or divided BID, is most optimal. I have used gabapetin or pregabalin in combination with duloxtine effectively. Venlafaxine (Effexor®), 75 mg-375mg (divided into BID or TID dosing), or in extended release form Venlafaxine ER (Effexor ER®) (37.5mg-375mg daily) can be combined with pregalin or gabapetin. Venlafaxine's cardiovascular side effects and lesser effectiveness serves HS patients less well then duloxetine, in my experience. An advantage of duloxetine and venlafaxine is that they can be used to treat the depression often associated with HS. If prolonged use of opiates is required, patients should be referred to a pain specialist.