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SummaryMore than 50 interventions have been used to treat hidradenitis suppurativa (HS), and so therapy decisions can be challenging. Our objective was to summarize and appraise randomized controlled trial (RCT) evidence for HS interventions in adults. Searches were conducted in Medline, Embase, CENTRAL, LILACS, five trials registers and abstracts from eight dermatology conferences until 13 August 2015. Two review authors independently assessed study eligibility, extracted data and assessed methodological quality. Primary outcomes were quality of life and adverse effects of the interventions. Twelve trials, from 1983 to 2015, investigating 15 different interventions met our inclusion criteria. The median trial duration was 16 weeks and the median number of participants was 27. Adalimumab 40 mg weekly improved the Dermatology Life Quality Index (DLQI) by 4·0 points, which equates to the minimal clinically important difference for the scale, compared with placebo (95% confidence interval −6·5 to −1·5 points). Evidence quality was reduced to ‘moderate’ because the results are based on only a single study. Adalimumab 40 mg every other week was ineffective in a meta‐analysis of two studies comprising 124 participants. Infliximab 5 mg kg−1 improved the DLQI score by 8·4 points after 8 weeks in a moderate‐quality study completed by 33 of 38 participants. Etanercept 50 mg twice weekly was ineffective. Inclusion of a gentamicin sponge prior to primary closure did not improve outcomes. Other interventions, including topical and oral antibiotics, were investigated by relatively small studies, preventing treatment recommendations due to imprecision. More, larger RCTs are required to investigate most HS interventions, particularly oral treatments and surgical therapy. Moderate‐quality evidence suggests that adalimumab given weekly and infliximab are effective, whereas adalimumab every other week is ineffective.

Analysis 5.6. Comparison 5 Adalimumab every other week versus placebo, Outcome 6 Proportion with improvement in pain..... Analysis 5.7. Comparison 5 Adalimumab every other week versus placebo, Outcome 7 Change in Sartorius scale score (LOCF)

SIR, A 43-year-old woman was referred to the dermatology department in 2002 because of a 5-year history of relentless, debilitating urticaria. Her past medical history was unremarkable but there was a family history of hypothyroidism (mother), multiple sclerosis (sister) and coeliac disease (daughter). Blood tests including full blood count, erythrocyte sedimentation rate, C-reactive protein, urea, creatinine, electrolytes, liver function tests, thyroid function tests, antinuclear antibodies, thyroid autoantibodies and C4 were all normal or negative. Autologous serum skin testing was not carried out.Cetirizine, loratadine, fexofenadine, hydroxyzine, chlorpheniramine, ketotifen, montelukast, cimetidine and doxepin were all tried in standard doses in various combinations. Cetirizine and loratadine were also tried at 20 mg daily with additional sedating antihistamines at night. None of these treatments conferred any significant benefit. Ciclosporin 4 mg kg )1 was given for 6 weeks. This cleared her urticaria but relapse occurred as soon as the dose was reduced below 3 mg kg )1 . Ciclosporin was not continued long term as the risks were felt to outweigh the benefits. A course of psoralen plus ultraviolet A (PUVA) was then tried twice weekly. This was effective but only during treatment. Urticaria relapsed within a week of discontinuing PUVA. Methotrexate was tried for 10 weeks, initially at 10 mg weekly, increasing to 15 mg weekly after 4 weeks. It Ó