What Is Hidradenitis Suppurativa?

Overview

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that causes small, painful lumps under the skin. In this article, we will explore the causes, signs and symptoms, management, and treatment options for hidradenitis suppurativa. It is a chronic skin condition that primarily affects areas of the body where skin rubs together and has sweat glands, such as the underarms, groin, and buttocks but it can sometimes affect other areas such as the neck or the belly.^1,4

Although it is also known as Verneuil's disease or acne inversa, it is not related to acne or infection. It is characterised by the formation of painful, inflamed nodules, abscesses, and tunnels beneath the skin. HS can significantly impact a person's quality of life, causing pain, discomfort, foul body odour, itching, and emotional distress.^2,3

Causes of hidradenitis suppurativa

The exact cause of hidradenitis suppurativa remains unknown but it is now believed that it is a multifactorial condition, meaning that it results from a combination of genetic and environmental factors, some of which are explored below:^1,3,4

• Hormonal Imbalance – HS often starts around puberty and may worsen before menstrual periods or during pregnancy. Hormones may affect the activity of the apocrine sweat glands, which are found in the affected areas of the skin
• Genetic Predisposition – HS tends to run in families. About 30-40% of people with HS have a family history of this condition
• Smoking – Smoking is proven to increase the risk of developing HS and may make it more severe
• Obesity – Being overweight or obese may increase the friction and pressure on the skin, which may trigger or worsen HS
• Bacteria – Some bacteria normally live on the skin. But with HS, they may become trapped in the blocked hair follicles and contribute to inflammation and infection
• Dysregulated Immune system – The immune system plays a major role in the body by producing inflammation and fighting infection. Some treatments that reduce the immune system activity may trigger the development of HS
• Other conditions – Because it is a multifactorial condition, HS may be associated with other skin disorders, such as acne, psoriasis, and pilonidal sinus. It may also be linked to some relatively common autoimmune disorders such as Crohn's disease or ulcerative colitis

It is worth noting however that HS is not caused by poor personal hygiene. It is also not shown to be a contagious or sexually transmitted disease.

Signs and symptoms of hidradenitis suppurativa

Because of the different factors that contribute to it, the signs and symptoms of hidradenitis suppurativa may vary from person to person. They may also change over time or depending on the stage of the condition.

The main signs and symptoms of HS include:^1,4,5

• Small, red bumps or blackheads that resemble acne
• Tender, swollen lumps or nodules that may be filled with pus or fluid
• Abscesses or boils that burst open and release foul-smelling drainage
• Sinuses or tunnels that connect the lumps under the skin
• Scars or skin changes that result from healing or repeated inflammation

The symptoms of HS can cause physical pain and discomfort, as well as emotional distress and social isolation. People with HS may experience:^2,5

• Difficulty moving or performing daily activities
• Problems with clothing or personal hygiene
• Infection or complications such as anaemia or fistulas
• Anxiety, depression, or low self-esteem
• Stigma, discrimination, or lack of support

Management and treatment for hidradenitis suppurativa

There is no definitive cure for hidradenitis suppurativa yet, but there are some ways to manage it effectively. The goals of management and treatments are to:^4,5

• Reduce inflammation and infection
• Prevent new lesions from forming
• Heal existing lesions and minimise scarring
• Relieve pain and discomfort
• Improve the quality of life and well-being

There are various management strategies and treatment options available to reach these goals. Specialist healthcare professional (dermatologist) will develop an individualised treatment plan which may include:^4,5

• Medications

Topical (over the skin) or oral (via mouth) medications, such as antibiotics, anti-inflammatory drugs, and hormonal therapy, may be prescribed to control infection, reduce inflammation, and manage hormonal imbalances respectively.

• Wound care

Proper wound care is crucial in managing hidradenitis suppurativa. Regular cleaning, dressing, and applying topical medications to the affected areas can help prevent infection and promote healing.

• Lifestyle modifications

Certain lifestyle changes can significantly improve symptoms. These may include weight loss (if applicable), smoking cessation, avoiding tight clothing, and practicing good hygiene to minimise bacterial growth.

• Surgical intervention

In more severe cases or when conservative measures mentioned above fail to provide relief, surgical interventions may be considered. Although most commonly a procedure known as incision and drainage of abscesses, removal of affected skin and tissue (excision) may be used, laser therapy is also shown to help manage symptoms and prevent recurrences.

FAQs

How is hidradenitis suppurativa diagnosed?

Diagnosis of hidradenitis suppurativa will be made by a dermatologist after a referral from your general practitioner (GP). The diagnosis process will include a physical examination and a review of your medical history. In some cases, additional tests such as a biopsy (taking a small part of the affected area to review under a microscope), swab culture (to check for bacteria), or imaging studies (such as ultrasound, X-ray, MRI or CT scan) may be ordered to rule out other conditions and confirm the diagnosis.^4,5

How can I prevent hidradenitis suppurativa?

There is no absolute way to prevent hidradenitis suppurativa, but reducing the risk of developing it or worsening it is possible by:^1-5

• Quitting smoking
• Losing weight if applicable
• Wearing loose-fitting clothing
• Maintaining good hygiene and washing the affected areas gently with mild soap and water to prevent bacteria overgrowth
• Avoiding shaving, waxing, or plucking the hair in the affected areas
• Avoiding irritants, such as perfumes, deodorants, or antiperspirants
• Managing stress and seeking emotional support

Who are at risk of hidradenitis suppurativa?

Anyone can develop hidradenitis suppurativa, but some factors may increase your risk, such as:^4,5

•  Being female
•  Having a family history of HS
•  African descent
•  Smoking
•  Being overweight or obese
•  Having other skin disorders, such as acne, psoriasis, or pilonidal sinus
•  Having inflammatory bowel disease, such as Crohn's disease or ulcerative colitis

How common is hidradenitis suppurativa?

Hidradenitis suppurativa is estimated to affect around 1% of the population. However, due to underdiagnosis and misdiagnosis, the actual prevalence may be higher.^1,4

What are the complications of hidradenitis suppurativa?

Hidradenitis suppurativa can lead to several complications, including the formation of abscesses, scarring, restricted movement, chronic pain, and emotional distress. In severe cases, it can also affect a person's ability to work or engage in daily activities.^1,4,5

When should I see a doctor?

If you are experiencing symptoms such as painful lumps, abscesses, or recurrent skin infections, it is advised to contact your GP. They can provide an accurate diagnosis (or a referral to a dermatologist if needed), offer appropriate treatment options, maintain a treatment regimen after the initial diagnosis, and most importantly help improve your quality of life.

Summary

Hidradenitis suppurativa is a condition that causes painful lumps under the skin and primarily affects areas where skin rubs together and has sweat glands, such as the underarms, groin, and buttocks. The exact cause is unknown, but it is believed to result from a combination of genetic and environmental factors.

The signs and symptoms of hidradenitis suppurativa vary and include small red bumps or blackheads resembling acne, tender swollen lumps, or nodules filled with pus, abscesses that burst open with foul-smelling drainage, sinuses connecting lumps under the skin, and scars resulting from healing or inflammation.

Although there is no cure for this condition, management with medications, wound care, lifestyle modifications, and in some cases, surgery, aims to reduce inflammation and infection, prevent new lesions, relieve pain, and improve quality of life.