Hidradenitis Suppurativa

Acne inversa, HS

Hidradenitis suppurativa is a long-term skin condition that causes painful lumps and abscesses in areas where skin rubs together, such as the armpits, groin, and under the breasts. While there is no cure, various treatments and lifestyle changes can help manage symptoms and improve quality of life.

Table of contents

• What is hidradenitis suppurativa?
• Signs and symptoms
• What causes hidradenitis suppurativa?
• Who is more likely to get hidradenitis suppurativa?
• How is hidradenitis suppurativa diagnosed?
• Treatment options
• Lifestyle changes and self-care
• Living with hidradenitis suppurativa

What is hidradenitis suppurativa?

Hidradenitis suppurativa, also known as acne inversa, is a chronic inflammatory skin condition that causes painful lumps to form under the skin^[1]. The condition affects areas where skin rubs together, creating painful, boil-like lumps that can break open and leak fluid^[3].

The lumps in HS form because of blockages of the hair follicles, which are the small openings in skin where hair grows. When hair follicles become blocked, bacteria get trapped inside, leading to inflammation and rupture^[3]. The condition is a chronic inflammatory skin disease characterized by deep-seated nodules, abscesses, skin tunnels (also called sinus tracts), and scarring^[2].

• Armpits
• Groin
• Buttocks
• Breasts (under the breasts)
• Perianal area
• Perineal area

Hidradenitis suppurativa is not contagious and cannot be spread to others^[3]. It is also not caused by poor hygiene^[4]. The condition is an autoinflammatory disease, which means your body attacks your hair follicles, resulting in chronic inflammation and scarring^[11].

Signs and symptoms

The symptoms of hidradenitis suppurativa can range from mild to severe. The condition typically causes a mixture of different types of skin problems^[5].

Early signs often include small pitted areas of skin containing blackheads, which appear in pairs^[1]. The condition usually starts with a single, painful lump under the skin that persists for weeks or months^[1].

As the condition progresses, more bumps may form, usually in areas where skin rubs together. These lumps become inflamed and painful, often breaking open and causing abscesses that drain fluid and pus^[3]. The drainage may itch and have an unpleasant odor^[3].

The abscesses heal very slowly and recur over time. They can lead to scarring and the formation of tunnels under the skin called sinus tracts^[3]. These narrow channels form under the skin and can break out on the surface, leaking pus^[5].

The most commonly affected areas include the armpits, groin, perianal and perineal regions, and the area below the breasts^[2]. Lumps may also appear on the nape of the neck, waistband, and inner thighs^[5].

Hidradenitis suppurativa can be classified as mild, moderate, or severe^[3]:

• In mild HS, there are only one or a few lumps in one area of the skin. A mild case often gets worse over time, becoming moderate disease.
• Moderate HS includes recurrences of the lumps that get bigger and break open. The lumps form in more than one area of the body.
• With severe HS, there are widespread lumps, scarring, and chronic pain that may make it hard to move.

Many people with hidradenitis suppurativa also develop a pilonidal sinus, which is a small hole or tunnel in the skin at the top of the buttocks^[5].

What causes hidradenitis suppurativa?

The exact cause of hidradenitis suppurativa is unknown, but the lumps develop as a result of blocked hair follicles^[5]. The blocked hair follicles trap bacteria, which leads to inflammation and rupture. In most cases, the cause of the blockages is unknown^[3].

Genetics, environment, and hormonal factors may all play a role in the development of HS^[3]. Some cases of HS are caused by changes in certain genes. Hidradenitis suppurativa runs in families in about 1 in 3 cases, and about 30% of people with HS have a family member who also has the disease^[4][5].

The condition usually starts around puberty, which suggests that sex hormones play a part^[5]. Many people with hidradenitis suppurativa also have acne and excessive hair growth^[5].

In rare cases, hidradenitis suppurativa may be linked to Crohn’s disease, particularly if it develops around the groin area and the skin near the anus^[5].

Smoking and obesity are both strongly associated with hidradenitis suppurativa. If you are obese or smoke, it will make your symptoms worse^[5].

Who is more likely to get hidradenitis suppurativa?

Hidradenitis suppurativa usually starts after puberty, typically in the teens or twenties, usually before age 40^[1][3]. However, it can also develop later in life, in your 40s or 50s^[4].

Women are three times more likely to develop hidradenitis suppurativa than men, though this ratio can differ by location around the world^[1][4].

People who are Black or biracial are more likely to develop this disease than people of other races. This could be attributed to genetic factors^[1][4].

Other risk factors include^[3][11]:

• A family history of HS
• Being overweight or having obesity
• Smoking
• Excessive hair growth (hirsutism)
• Fluctuating sex hormones (estrogen and androgens), which is common after puberty and before menopause

How is hidradenitis suppurativa diagnosed?

There is no specific laboratory test for hidradenitis suppurativa^[3][8]. The condition can be hard to diagnose in the early stages because it can look like pimples or acne. Hidradenitis suppurativa can be mistaken for pimples or acne, and for many people, it takes years to receive a correct diagnosis^[8].

To make a diagnosis, your health care provider^[3]:

• Will ask about your medical history and your symptoms
• Will look at the lumps on your skin
• May take a sample of the skin or pus (if there is any) and send it to a lab to be tested

Your health care provider will base a diagnosis on your signs and symptoms, skin appearance, and medical history^[8]. If pus or drainage is present, your health care provider might take a sample for lab testing^[8].

Your provider may refer you to a dermatologist, a doctor who specializes in skin conditions, to get a diagnosis or treatment^[3][8]. Hidradenitis suppurativa requires specialized care^[8].

Treatment options

There is no cure for hidradenitis suppurativa^[3][5]. However, treatments focus on managing symptoms and preventing complications. Treatment with medicines, surgery, or both can help control symptoms and prevent complications^[8].

The treatments depend on how severe the disease is and may include medicines, procedures, or surgery^[3].

Medicines

Your health care provider might prescribe one or more types of medicines^[8]:

Antibiotics may be used to manage symptoms. An antibiotic applied to the skin in liquid or gel form (topical antibiotics) may be used for mild symptoms. For more widespread disease, your health care provider might prescribe antibiotic pills, such as doxycycline, clindamycin, or rifampin, or more than one of these medicines^[8]. Antibiotics can be used for a week or two, or months at a time, and can also be used in combination with other treatments^[12].

Steroids may be injected into lesions to reduce pain and swelling. These injections don’t help HS bumps in other places, so they typically aren’t a great way to control the HS over many years^[12]. Steroid pills can be used to lower inflammation, but they can have side effects if used for a long time, so they are often used for a range of one to several weeks to treat a flare-up^[12].

Hormone therapy pills that influence the hormones in the body can also help treat HS. Your hormones can influence your immune system and your skin. These pills aren’t antibiotics and can be used for years, if needed^[12].

Biologic medicines are injected or infused through an IV and are meant to treat all areas of HS. Many of these medicines lower the overactivity of the immune system but target just a couple of the chemicals in the immune system. Consequently, they aren’t lowering the whole immune system^[12].

Other medicines may include pain relievers and medicines that fight inflammation^[3].

Procedures and surgery

Procedures are used to decrease inflammation in the skin by changing the structure of the skin. Procedures can vary from laser treatments that don’t break the skin, to lancing the skin, to small surgeries that can often be done in a clinic, or larger surgeries that may require a hospital operating room^[12].

A deroofing is a procedure done in the office while you are awake. The top of a tunnel of HS is removed^[12]. Other procedures may include laser therapy and excision with skin grafting^[2].

Surgery may be required in severe or persistent cases^[5]. In some cases, particularly with severe HS, wide excision may prove to be the only effective treatment^[13].

Supportive therapies like pain management and psychological support may also benefit patients^[2].

Lifestyle changes and self-care

Making targeted lifestyle changes can play a crucial role in managing symptoms and promoting better health. These adjustments often aim to address individual triggers, reduce inflammation, and support overall skin health^[17].

It may help if you can avoid things that irritate your skin, by^[3]:

• Wearing loose-fitting clothing
• Staying at a healthy weight
• Quitting smoking
• Avoiding heat and humidity
• Being careful not to injure your skin

Monitoring and avoiding triggers

HS flare-ups can be triggered by various factors, which may differ from person to person. Identifying and avoiding these personal triggers can help manage symptoms and prevent flare-ups^[17].

Friction from tight clothing, rigorous exercise, and repetitive movements can cause friction in affected areas, potentially making symptoms worse. Choose loose-fitting, breathable clothing and minimize activities that cause friction when possible^[17].

Sweating can aggravate HS lesions, making it essential to keep affected areas clean and dry. Consider using mild, unscented soaps and moisture-wicking materials to maintain dry skin and reduce irritation^[17].

Stress can negatively impact the immune system and may contribute to HS flare-ups. High stress levels and chronic inflammation can make both stress and HS worse^[21]. Incorporate stress-management techniques such as meditation, deep breathing exercises, or yoga into your daily routine^[17].

Skin care

Maintaining good skin care is important for managing HS. Use daily antiseptic wash to cleanse affected areas. Specific types of body wash, antiperspirants that are gentle on delicate skin, and retinoids may help reduce inflammation^[11].

Keep the affected area clean by gently washing with antibacterial soap. Wear loose-fitting and breathable clothing to reduce friction on your skin^[15]. Avoid shaving where you have breakouts. Some patients don’t shave their underarms and instead use an electric trimmer to closely trim the hair^[15].

Applying warm compresses or a warm washcloth can help reduce swelling. Placing a hot tea bag that’s been steeped for a minute on the painful abscess or nodule may also help. Try ice or a cold compress for localized pain^[15].

Diet

Although there is no specific diet for HS, certain foods may contribute to inflammation or trigger flare-ups. Adopting a balanced, anti-inflammatory diet may help manage symptoms by reducing inflammation and supporting overall skin health^[17].

Focus on consuming a variety of fruits, vegetables, lean proteins, whole grains, and healthy fats while avoiding processed foods, refined sugars, and unhealthy fats. Include foods rich in omega-3 fatty acids, such as fatty fish, nuts and seeds, and leafy greens, which can help combat inflammation^[17].

Managing pain and discomfort

Hidradenitis suppurativa treatment includes therapies to relieve pain. Options include complementary medicine like dietary mind-body techniques and acupuncture, ice packs or warm compresses, lidocaine skin cream or ointment, and over-the-counter or prescription pain medications^[11].

Living with hidradenitis suppurativa

Hidradenitis suppurativa is a lifelong condition, so you will have to manage it for life^[18]. For most people, it’s a cycle of flare-ups and periods when their skin is clear. Some women find their HS clears up after menopause^[18].

The condition’s impact extends beyond physical discomfort. The associated pain, drainage, malodor, and scarring often lead to profound negative psychosocial implications for affected individuals^[2]. Because of the difficulty of dealing with the disease, people with HS are at risk for depression and anxiety^[3].

Treatment can keep HS from getting worse and help you avoid the most serious symptoms. The key is to start treatment early^[18]. Interprofessional care is crucial to creating a personalized treatment plan, with regular follow-up appointments to monitor effectiveness and make adjustments as necessary^[2].

You should expect to have regular follow-up visits with your dermatologist^[8]. Your symptoms and the way your body responds to treatment will determine how often you see your doctor^[18].

Potential complications

People with HS tend to have other conditions, including severe acne, arthritis, heart disease, diabetes, obesity, and inflammatory bowel disease. Doctors don’t know exactly why these conditions are linked, but it may be that whatever causes HS leads to other problems, too^[18].

Longstanding untreated HS increases your risk of anemia, cellulitis, damage to your body’s lymphatic system, fistula, scars, sepsis, and, rarely, skin cancer^[11][18]. Some of the lumps may become infected with bacteria, causing a secondary infection that will need to be treated with antibiotics^[5].

Support and resources

Working with a therapist, staying active, and practicing mindfulness are just a few ways to help manage stress and improve your quality of life^[21]. Joining a support group can help, as knowing you aren’t alone in this experience is important^[11].

Playing an active role in your care is important. The best treatment plans are a team effort. Work alongside your provider to develop a treatment plan that fits your needs^[11]. Keep an open line of communication with your doctor, and never stop taking a medication without consulting with your provider^[11].