Hidradenitis suppurativa (H.S., or also acne inversa) is an inflammatory skin condition known for the severe pain it causes. As the disease progresses it results in the growth of abscesses, nodules, and eventually, tunnels underneath the skin
These abscesses grow when hair follicles become blocked and burst, spreading bacteria. In the beginning, H.S. can be mistaken for acne, or pimples, because it often shows up as a small and painful lump (also called a nodule).
Patients who visit the E.R. are frequently misdiagnosed for this disease.
Overview
This skin condition can be extremely severe. When the abscesses pop, they drain pus and blood, releasing a foul odor. Range of motion can become limited by scarring and pain. People with H.S. are often given mental health resources due to the isolating and extremely stressful/depressing experience of living with H.S.
Hidradenitis suppurativa tends to occur in areas where skin rubs together.
It is important to keep in mind, however that because HS tends to form in these areas, it can form anywhere there is a hair follicle.
The only places HS cannot form are the soles of our feet, palms of our hands, and the red of our lips.
Most commonly it appears:
- Groin
- Buttocks
- Armpits
- Under breasts
- Under folds of the belly
- Thighs
- Nape of the neck
(Nodules or Abscesses forming underneath the skin)
H.S. is very strongly linked to obesity and smoking cigarettes. It has been shown that reducing body weight, and quitting can reduce the severity of symptoms and in some cases get rid of them. This is a case-by-case outcome though, and H.S. is often a long term condition. If diagnosed and treated early, the progression of symptoms can be slowed. Doctors recommend overweight individuals lose weight, and that smokers stop smoking to improve hidradenitis suppurativa symptoms.
Causes of Hidradenitis Suppurativa
The exact cause of hidradenitis suppurativa has not yet been discovered, but we do understand a fair bit about it.
When the tiny hole in our skin where the hair grows from (the hair follicle) becomes blocked, bacteria and sweat begin to build up inside. Once it can’t hold any more, it bursts, spreading the sweat and bacteria under the skin. This pocket of fluid under the skin is what creates the tender abscesses. The lumps fill with pus, and eventually pop, possibly draining blood and pus.
Hidradenitis suppurativa can spread when it reaches and blocks more hair follicles.
It is thought that hormonal and genetic factors play a part.
There is an increased chance of developing H.S. when it runs in the family. It is less likely in white people than it is in biracial, black, or hispanic people.
Hidradenitis is linked to psoriasis, and in rare cases, crohn’s disease.
Typically it only develops after puberty and before the age of 40 years old.
H.S. is nearly three times more common in women than men.
In people with H.S. it is found that there is often an overactive immune system. Scientists are still trying to determine if it is an auto-immune disorder, or an inflammatory one. If it were an auto-immune disorder, the source would be the immune system.
It is a myth that poor hygiene causes H.S.
Symptoms of Hidradenitis Suppurativa
H.S. can result in:
- Painful lumps, or abscesses under the skin. These may vary in size and severity, and as the condition progresses may become recurrent and spread.
- Leaking pus and blood from ruptured abscesses.
- Scarring from wounds caused by bursting nodules and the healing process afterwards. As abscesses recur scarring becomes a larger concern.
- Foul odor from pus and possible presence of infection under the skin.
- Anxiety, isolation, feelings of embarrassment and depression.
- Blackheads.
- Tunnels that form underneath the skin. These tunnels, also called sinus tracts, form connecting spots of inflammation and contribute to the progression of the disease.
The pain from hidradenitis suppurativa is both inflammatory and non-inflammatory.
Pain can come from the tender abscesses, keloids (a raised scar), scarring (causing tensile pain when it stretches), the sinus tracts (or tunnels), friction, arthritis, open wounds, or the build up of lymph fluid in the body.
Hidradenitis suppurativa can start off with relatively mild symptoms.
In the beginning, an area of the skin may sweat a lot, burn, or itch. It may be uncomfortable, but it gets much worse.
As H.S. progresses, a lump appears on the skin. It may be painful to touch, and is often referred to by several different names: abscesses, boils, cysts, nodules. The pain is a severe throbbing and tenderness, and the nodule may be deep within the skin.
A pus filled abscess
As the cellular materials within are spread to more hair follicles, more nodules appear. These may be connected by channels or tunnels underneath the skin. The abscesses swell and build in pressure and pain until eventually they pop on the outside and drain pus and blood.
Blackheads are also a common outcome of hidradenitis suppurativa.
Mental Health
Hidradenitis suppurativa can be socially isolating. On top of limiting a person’s ability to do their job, and participate in life, people may feel embarrassed, particularly by the smell that comes from H.S. lesions.
During a flare-up, some people are unable to move for upwards of a week due to the intense pain. These isolating flare-ups can be emotionally draining and very frustrating.
Diagnosis
While known for being hard to diagnose, a dermatologist will be trained to identify hidradenitis suppurativa.
The dermatologist will base their diagnosis off the location of abscesses as well as a visual inspection.
In some cases a dermatologist may take a swab of the fluid that leaks out to determine if there is an infection.
Early diagnosis is critical in the prevention of symptom progression, but unfortunately, in many cases diagnosis of HS can take 3-10 years after the initial symptoms show up. This is why it’s important that the medical community push towards greater education on diagnosis.
It’s important to note that while data shows both common places for H.S. to arise, and a higher prevalence by sex and race, that H.S. can show up nearly anywhere on anyone. Using prevalence data to guide diagnosis can lead to misdiagnosis which results in greater symptom progression and more suffering.
Wound Care
Wound care is a crucial aspect of managing Hidradenitis Suppurativa (HS) effectively. Given the frequent bursting of pus-filled nodules and the potential need for surgical interventions, knowing how to care for wounds is essential. Here’s a step-by-step guide to proper wound care for individuals with HS:
- Gentle Cleansing: Start by gently cleaning the affected area with mild soap and lukewarm water. Avoid harsh scrubbing to prevent further irritation. Pat the area dry with a soft towel afterward.
- Dressing Application: If the wound is draining, cover it with a sterile, non-adherent dressing to absorb excess fluid and protect the surrounding skin. Change the dressing regularly to maintain cleanliness.
- Use of Absorbent Dressings: Consider using absorbent dressings designed for wound exudate management if the wound is actively draining. These dressings can maintain a moist wound environment while promoting healing.
- Topical Medication Application: If prescribed by a healthcare provider, apply prescribed topical medications such as antibiotic ointments or corticosteroid creams to the wound as directed. These medications can aid in reducing inflammation, preventing infection, and promoting healing.
- Monitoring for Infection Signs: Keep a close watch on the wound for any signs of infection, including increased redness, swelling, warmth, or foul-smelling drainage. Contact your healthcare provider promptly if you notice any concerning symptoms.
- Protection of the Wound: Prevent further trauma or irritation to the wound by avoiding tight clothing and activities that may aggravate the area. Consider using padding or cushioning for additional protection during daily activities.
- Follow-up Care: Attend scheduled follow-up appointments with your healthcare provider to monitor the wound’s healing progress and address any underlying issues promptly.
By following these steps and maintaining good wound care practices, individuals with HS can support healing, minimize complications, and improve overall skin health.
It’s crucial to collaborate closely with healthcare providers to develop a personalized wound care plan tailored to individual needs and condition severity.
Treatment
There are three main goals when treating Hidradenitis Suppurativa:
Treating existing nodules to minimize pain and drainage
Preventing the progression of H.S.
Reducing the frequency of occurrence.
Treatment plans are based on how far H.S. has progressed, but with consideration of other health factors. Age, general health, and any unique concerns all play a part.
This progression is categorized into what is called the Hurley staging system, seen on the right.
Treatments for Hidradenitis Suppurativa
- Antibiotics
- Corticosteroids
- Excision and Drainage
- Retinoids
- Hormone Therapy
- Laser Hair Removal
- Deroofing
- Botox
- Biologics
- Wide Excision
One of the first options for Hidradenitis Suppurativa is antibiotics, but all treatment must be case-by-case. They may be given on their own or in combination with another treatment.
Antibiotics control bacterial growth, and can be anti-inflammatory. This reduces the risk of infections and reduces the pain and progression of H.S.
Corticosteroids can slow down H.S. progression and significantly improve a person’s quality of life.
Topical or injected corticosteroids can reduce inflammation, control the immune system response, slow production of cells, and reduce blood flow to certain areas.
This reduces pain by lowering inflammation.
Whether a doctor prescribes topical, oral, or injected steroids is based on severity of H.S. symptoms and other factors such as age, and overall health.
In this procedure the doctor cuts the abscess open and drains the fluid from within. It helps to deal with immediate pain and discomfort from having built up pressure in the abscess, but does not prevent it from returning.
Retinoids reduce pain, swelling and inflammation in people with Hidradenitis Suppurativa. Usually recommended as the second or third line of treatment, retinoids work by slowing the production of certain cells in the body.
The goal of retinoids is reducing the keratin production responsible for blocking the hair follicle.
Retinoids have been shown to reduce symptoms but they do come with side effects and shouldn’t be used by certain people.
Studies have shown mixed results from using retinoids. In some cases it works, in other cases it doesn’t.
While not entirely understood quite yet, hormones play a role in H.S. The most common drugs for hormone regulation in treating H.S. are spironolactone and finasteride, but there are a few others that are used.
It has been found that hormonal therapies can work but studies have shown results to be mixed.
In an ideal situation these drugs have shown to reduce pain, inflammation, and flare-ups.
Using hormone therapy is complicated due to the potential side effects and the many different bodily systems that interact with our hormone levels.
Laser hair removal aims to remover the hair follicle responsible for causing H.S. but it can be very expensive and doesn’t always work.
It is primarily used in treating the first two stages of H.S., before there are multiple tunnels underneath the skin. Most people need more than 3 treatments to begin to see results.
There is also a possibility that the procedure will cause more inflammation and worsen symptoms. Laser treatment isn’t a good option for everyone and results vary.
When H.S. symptoms do not improve with antibiotics and topics, deroofing is often necessary. This procedure involves surgically removing the surface of the skin over abscesses and skin tunnels and removing any inflamed skin material.
It has a fairly high success rate. In a 2010 study it was found that 77% of deroofing procedures did not re-occur within 34 months. Another study from 2022, put the success rate at 80%.
Despite this success there are potential complications. There is approximately a 12.5% complication rate, which could mean anything from postoperative bleeding, infection (rare), and scarring.
It also hurts to receive the numbing agent that the surgeon uses before the procedure, and during the healing process. It is generally considered worth it though because the healing pain is nearly the same as from symptoms of H.S. and if successful, there would be no more lesions.
Most people only need to take a single week off of work following the surgery and can resume physical exercise after two weeks. The surgery heals after approximately 4-5 weeks.
Studies have shown that botox can work for treating H.S. primarily because it reduces sweating.
A review of research done on this treatment conducted in late 2022 noted that there wasn’t a lot of research for this, but that it generally seemed effective. They pointed out that due to Hidradenitis Suppurativa affected everyone in widely different ways, the limited research meant that we still didn’t have a great understanding of botox for H.S.
Biologics are some of the most advanced treatment methods offered by medical science.
These drugs work by controlling the immune system response that creates pus and inflammation. Currently only one is approved by the FDA for use in treating hidradenitis suppurativa and that is adalimumab.
Studies have shown that it has a good success rate in reducing the formation of new nodules and abscesses greater by than 50%.
There have been a fair amount of studies into the efficacy of adalimumab, but the study of other biologics is relatively limited.
As medical science continues to advance, and with the projected integration of artificial intelligence into the research industry, it’s not unreasonable to imagine that we will understand far more about how to treat H.S. with much greater accuracy.
Wide surgical excision is typically recommended for severe cases of hidradenitis that haven’t responded well to other treatment.
It is an aggressive approach targeting the source of the problem. Like any surgery, there are risks involved, such as infection, scarring, and potential complications with wound healing.
During the procedure, the surgeon carefully cuts out the lumps, along with some of the surrounding healthy tissue. This is called a “wide” excision because they remove a larger area around the affected site to make sure they get all of the diseased tissue. After removing the tissue, the surgeon may close the wound with stitches or leave it open to heal on its own, depending on the size and location.
Recurrence rate varies widely by study. In some studies H.S. symptoms clear up completely for up to 90% of patients, but in others this might come down to 60%.
References
Cleveland Clinic – Hidradenitis Suppurativa
American Academy of Dermatology Association – Hidradenitis Suppurativa
Mayo Clinic – Hidradenitis Suppurativa
NHS – Hidradenitis Suppurativa
American Academy of Dermatology Association – Hidradenitis Suppurativa Signs and Symptoms
National Institute of Arthritis and Musculoskeletal and Skin Diseases – Hidradenitis Suppurativa
National Library of Medicine – Hidradenitis Suppurativa
National Library of Medicine – Clindamycin
HS Source – HS Pathophysiology
HS Disease – Hormonal Therapies
Healthline – Laser Hair Removal for Hidradenitis Suppurativa
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