Role of FDG-PET in Evaluation of Hidradenitis Suppurativa: History
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Contributor:
Sahithi Talasila
,
Eric M. Teichner
,
Robert C. Subtirelu
,
David H. Xiang
,
Cyrus Ayubcha
,
Thomas Werner
,
Abass Alavi
,
Mona-Elisabeth Revheim

Hidradenitis suppurativa (HS) is a chronic skin disorder characterized by nodules, comedones, and sinus tracts that often leave prominent scarring. Non-invasive imaging techniques have been used to assess the inflammatory activity, vascularization, and treatment response of lesions. Specifically, fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) scans may aid in identifying systemic inflammation in patients with HS, improving diagnosis. Inflamed hypermetabolic tissues exhibit a greater uptake of FDG due to increased glucose uptake and vascularity.

  • hidradenitis suppurativa
  • non-invasive imaging techniques
  • fluorine-18 fluorodeoxyglucose
  • FDG-PET/CT
  • systemic inflammation
  • diagnosis
  • treatment follow-up
  • SAPHO syndrome

1. Introduction

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disorder characterized by recurrent nodules, abscesses, comedones, and sinus tracts that often leave prominent scarring in the axilla, groin, perianal, inframammary, and intermammary folds [1][2][3]. HS is more prevalent in women than men and affects up to 4% of the global population, with an estimated annual cost of $6500 per patient [4]. In one study, nearly half of the patients indicated that they could not afford the dressings and wound care supplies they would prefer in terms of both type and quantity [4].
Additionally, HS negatively impacts quality of life, as the lesions can be painful, disfiguring, and malodorous, hindering activities of daily living [5][6][7]. Specifically, one study demonstrated that said features of HS can result in significant impairments that commonly exceed other dermatoses, including psoriasis, atopic dermatitis, and acne vulgaris. Due to the severity of HS, significant psychological distress and psychiatric comorbidity may be concomitantly observed with the disease. Patients with HS endure a compromised quality of life, battling excruciating pain, recurrent abscesses, and chronic inflammation. The condition’s physical and emotional toll often leads to limited mobility, social isolation, and a profound impact on their overall well-being [8]. Unfortunately, treatment courses are often partially efficacious, and many patients are left with the aforementioned sequalae [8].
Although the exact pathophysiology of HS is unclear, the prevailing theory is that the condition is caused by the follicular occlusion of the folliculopilosebaceous unit, followed by rupture and inflammation [9][10][11]. Furthermore, a mutation in the γ-secretase enzyme that leads to the failure of keratin degradation has been linked to HS [12][13]. Risk factors include obesity, hormonal changes experienced during the postpartum and premenopausal states, stress, family history, and environmental factors such as smoking and mechanical friction [14]. Shaving or waxing, as well as friction from tight clothing, can aggravate inflammation by further disrupting hair follicles [14][15].
HS is a chronic condition characterized by inflammation, pain, pus formation, tissue damage, and scarring. Immune cells and cytokines play a significant role in the development of HS [16]. Keratin fibers and other debris from tissue destruction and scarring activate Toll-like receptors (TLRs) on macrophages and dendritic cells, leading to the production of the pro-inflammatory cytokines, tumor necrosis factor alpha (TNF-α), interleukin (IL)-17, and IL-1β [17]. The NLRP3 (nucleotide-binding domain, leucine-rich family pyrin domain containing 3) inflammasome is the best-characterized inflammasome and is activated by the release of material from follicles, leading to the production of IL-1β and neutrophil involvement [18]. HS lesions have reduced levels of IL-22, leading to an increased production of IL-10 due to increased IL-1β [1][19][20]. This intricate interplay between immune cells and cytokines creates a self-sustaining cycle of inflammation, causing recurrent pain, purulence, tissue damage, and scarring in HS patients [21].
These findings emphasize that comprehensive management is crucial in treating HS, with various treatments available depending on the severity of the condition [22]. Mild cases are treated with topical clindamycin and dapsone, while stages 1 and 2 HS involve combining rifampin with either oral clindamycin or minocycline. These antibiotics function to reduce inflammation, infections, and new lesions in HS. Prolonged antibiotic regimens are often used to control HS; however, this strategy may be inducing antibiotic resistance. One study found that lesions of HS patients on prolonged antibiotics grew significantly more antibiotic-resistant bacteria. These results underscore the importance of antibiotic stewardship when managing HS [23]. Alternatively, hormonal treatments such as oral contraceptives, spironolactone, and finasteride have also been used as adjuncts in severe disease or in mild-to-moderate presentations. As increased levels of androgens cause the folliculopilosebaceous gland to secrete more sebum, the mechanism of hormone therapy to treat HS functions by balancing testosterone and 5-dihydrotestosterone (5-DHT) levels [23]. Severe cases may require treatments like adalimumab, intravenous carbapenems, isotretinoin, laser therapy, and surgical excision. Adalimumab is a monoclonal antibody that targets TNF-alpha, blocking the inflammation that contributes to abscess, inflammatory nodules, and draining tunnels. Carbapenems function as broad-spectrum antibiotics, and isotretinoin inhibits keratinization and sebaceous gland function, resulting in smaller glands that are less likely to be clogged. Surgical interventions for HS encompass procedural approaches like laser therapy and minor surgical procedures, including incision and drainage or deroofing. A more extensive surgical option for severe disease would be wide local excision [23]. Laser Speckle Contrast Analysis (LASCA) is an innovative tool with diverse applications in dermatology and dermatosurgery. It measures speckle contrast to assess local blurriness in images, linked to tissue blood perfusion. LASCA effectively estimates skin microcirculation and aids in HS evaluation. It detects imperceptible foci and post-operative outcomes, including ischemic necrosis and lesion area assessment for surgical precision [4][23].
The diagnosis of HS is primarily a clinical one; however, histopathology is the gold standard for a definitive diagnosis [22]. Clinical diagnosis is made by the modified Dessau definition, which assesses the type of lesions, their location, and the patient’s medical history [23][24]. Specifically, three diagnostic criteria must be present [25]. First, there must be the presence of deep-seated painful nodules or other characteristic lesions, which can resemble abscesses, bridged scars, draining sinus, or post-inflammatory, open, tombstone double-ended comedones. Second, the lesions must appear in one or more of the predilection areas, including the axillae, inframammary and intermammary folds, groin, perineal region, or buttocks. Lastly, the disease must be chronic and recurrent, with at least two recurrences over a six-month period [25].
Other factors, including a family history of HS, recurrent uncharacteristic lesions, and the absence of pathogenic microbes, may also support the diagnosis [26]. The clinical presentation of painful lesions in the predilection areas, along with their recurrent and chronic nature, is usually sufficient for a self-reported diagnosis with a high degree of accuracy [27]. However, an observation period may be necessary to confirm the diagnosis in cases where there is no history of recurrence and chronicity, with a delay in diagnosis not exceeding six months [28].
As such, a more objective method for the diagnosis of HS is necessary. In recent years, non-invasive imaging techniques have grown in popularity for the assessment of the extent, inflammatory activity, vascularization, and treatment response of HS lesions. Imaging methods can also help prevent misdiagnosis and reduce diagnostic delays when HS is suspected [29]. However, there are limited publications on the subject.
Fluorodeoxyglucose positron emission tomography (FDG-PET) measures the metabolic activity of the cells in body tissues, allowing for the detection of inflammation, cancer, and infection [30][31]. While FDG-PET imaging is primarily used in the field of oncology, it has proven useful in other medical areas of cardiac and brain imaging. FDG-PET is known for its high sensitivity in detecting cellular inflammation in tissues and early signs of atherosclerosis [32]. Specifically in dermatology, FDG-PET has been used to ascertain systemic and vascular inflammation in psoriasis, detecting inflammatory lesions in the skin, blood vessels, joints, and liver [33]. Tissues that are hypermetabolic and inflamed exhibit a greater uptake of FDG compared to surrounding tissues, due to increased glucose uptake and vascularity. This distribution of FDG throughout the body allows clinicians to identify hypermetabolic tissues, as well as inflammatory and infectious conditions [29].

2. The Role of FDG-PET in the Evaluation of Hidradenitis Suppurativa

One review analyzed 63 studies concerning the use of various radiological techniques in managing HS. The authors concluded that providers were advised to employ ultrasonography for monitoring lesion progression and pharmaceutical treatment efficacy, as well as for accurate disease staging. To assess deep-seated disease manifestations, both CT and MRI were recommended, with MRI offering superior resolution and greater accuracy in depicting margin delimitation and radiologic features such as content and tunnel aperture. Although fistulography and mammography can be used to detect HS, they were most effective for assessing lesions. Imaging reports for HS have increased in recent years, leading the authors to suggest incorporating imaging techniques into routine clinical practice for HS patients.
Three case reports were retrieved from a search on FDG in cancer patients who incidentally had HS. It should be noted that these PET/CT examinations were not performed to detect HS, and the hypermetabolic subcutaneous lesions identified were not indicative of metastases but rather were consistent with HS. Additionally, it is important to consider the patient’s medical history when evaluating an atypical distribution of hypermetabolic foci to avoid misdiagnosis. Infection, sarcoidosis, surgery, and minor trauma such as intramuscular and subcutaneous injections can all lead to an increased metabolism in subcutaneous tissue. CT imaging is deemed inferior to PET imaging for HS, although PET has limitations in visualizing anatomic localization and lesion extensions. Thus, combining CT with PET imaging can facilitate HS visualization, and scintigraphy is capable of detecting small lesions with a full-body scan. Providers may use both PET/CT and PET/MRI as useful preoperative techniques to assess the extent of the lesion, detect subclinical lesions, and identify other complications, such as SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteitis) associated with HS. However, no standardized method currently exists for identifying subclinical lesions. The evidence powering this review comprises 63 studies discussing HS and various radiologic imaging techniques, and includes randomized controlled trials, systematic reviews, books, observational studies, case reports, and case series [34].
Another review article that focused on imaging techniques in HS analyzed 55 studies concerning the use of ultrasound, MRI, PET, and CT for the diagnosis, management, and treatment of HS. Ultrasound (US) and MRI are the two main imaging techniques currently employed in HS patients, with MRI having a narrower range of use. US is well-studied and has improved the staging, pre-operative planning, and disease monitoring in HS patients. Almost any HS lesion can be effectively imaged by US, except for severe subcutaneous lesions.
Despite these limitations, FDG-PET/CT can be utilized to provide a more objective identification of HS through enhanced visualization. For example, early functional changes can be detected before anatomical changes occur, which allows for an earlier initiation of treatment. In one particular study, it was found that FDG-PET/CT scans were able to detect subclinical skin lesions in up to 84.4% of HS patients [33]. Additionally, this imaging technique allows for the whole body to be imaged in one session, which helps clinicians determine the optimal timing for treatment initiation or modification based on the disease burden. For instance, patients with extensive subclinical lesions (and a high disease burden) may require more aggressive treatment and a longer duration of systemic therapy. Mapping disease burden can also be useful for prognostication and early identification of individuals with potentially more severe or refractory disease courses. In HS patients, FDG-PET/CT scans did not reveal any evidence of systemic inflammation, unlike in patients with psoriasis, where FDG uptake was observed in multiple organs. The authors speculate that systemic inflammation may develop only after a prolonged period. The study participants were mostly young, and follow-up with repeat FDG-PET/CT scans would be necessary to evaluate the potential development of systemic inflammation [33].
There have been previous reports linking HS with various types of malignancies. In one study, it was found that almost 10% of patients had high FDG focal uptake over the thyroid glands, and two of these patients were confirmed to have papillary thyroid carcinoma. It was observed that papillary thyroid cancer was the most commonly reported malignancy, which corresponds with the current literature on this subject. This study also reported a 50% increased risk of all types of cancer in HS patients when compared to matched controls, with a higher risk for nonmelanoma skin cancer, buccal cancer, and primary liver cancer [33]. The high percentage of thyroid nodule detection and its association with malignancy in this small group of HS patients indicate a significant correlation that requires further investigation, specifically where FDG-PET/CT scans could detect malignancies and HS in high-risk patients.
Additional research into radiologic techniques has provided valuable information regarding HS [35][36][37]. Ultrasonography has been used to study healthy hair follicles and revealed elongated, low-echogenic structures in a regular pattern within the dermis at an angle of around 45° to 60° to the surface of the skin [38]. In HS, follicles have a larger diameter and distorted shape, and hair shafts appear as bilaminar hyperechoic linear structures retained within pseudocysts, abscesses, or fistulas [39]. This can be useful in identifying children with HS, as they have a higher prevalence of retained hair tracts within fluid collections and fistulous tracts as compared to adults [40]. Ultrasonography can also be used to assess skin thickness, resistance, density, and vascularization, with blood flow being generally higher around fluid collections and fistulous tracts coexisting with slow arterial and venous flow areas [41]. Interestingly, even perilesional areas that appear healthy and unaffected by inflammation can be seen as affected by HS when scanned [42].
However, there are some limitations to using US imaging that PET scans can address. Distinguishing between small vasculature and developing sinus tracts, especially at the borders of HS lesions, is challenging for US imaging, which limits its effectiveness and accuracy in detecting the full extent of HS lesions [43][44]. Additionally, US imaging is operator-dependent and requires specialized training and experience in HS detection to achieve proficiency. Obtaining US images can also be time-consuming, making it challenging to incorporate it into clinical practice [45]. Moreover, HS patients may experience pain due to the physical contact required to obtain US images. Lastly, HS lesions can be deep-seated, and US imaging may not be able to penetrate the required depth, making it less useful, especially in larger patients [46]. FDG-PET scans can overcome these limitations and have a role in the diagnosis and management of HS patients, particularly in situations where US imaging is not feasible.

This entry is adapted from the peer-reviewed paper 10.3390/jcm12175491

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