Hidradenitis Suppurativa

What is Hidradenitis Suppurativa?

  • Hidradenitis suppurativa (HS), also known as acne inversa (AI), is a common, painful, debilitating, and chronic inflammatory skin disease affecting 1-4% of the global population, primarily occurring in the crease areas of the skin, e. g. axillae (armpits) and groin.
  • HS usually produces painful and chronically recurring, deep-seated follicular papules and pustules.
  • They may enlarge to become nodules, may form abscesses that discharge foul-smelling pus, leading to nodular scars and distortion of the skin.
  • The tendency of the process to cause tunnels ultimately leads to inter-connected sinuses and attempts to heal these leads to thickened scars.

What are the causes of Hidradenitis Suppurativa?

The search for the cause of HS has been difficult. Suggested causes include:

  • Hormones/hormone imbalance
  • Local factors including heat and humidity, sweating, rubbing of skin-to-skin
  • A reaction to deodorants or other topical chemicals
  • Abnormal inflammatory responses to follicle rupture
  • Abnormal responses to normal bacteria in the skin
  • Abnormal healing responses to follicular injury
  • Diet
  • Heredity and
  • Abnormal control of growth factors within the follicle/pore.

Ratio: F:M is 3:1


Manifestations of HS

Local Lesions:

  • Individual lesions may consist of inflammatory bumps, similar to pimples, usually occurring in the creases: the underarms, groin, under breasts, and between buttocks. Small pimple-like lesions may progress to become nodules, pustules, or soft tender reddish-purple masses that look like boils.
  • With repeated inflammation and scarring, there may develop sinus tracts, inter-connected tunnels under the skin where pressure on one area may express pus from a pore distant from the original point of pressure. Lesions are typically painful, and may drain a foul-smelling material. Large amounts of pus are common, and may lead to staining of clothing, lesions will fill with a gelatinous substance and extend further under the skin, especially in pressure areas. These look like a large boil but are purplish-red instead of hot red, are broad-based instead of localized, and do not ‘point to the surface and rupture and discharge and heal like a true infected boil.
  • Although early lesions may come and go, these gel-filled cavities, the tunnels, and the scars that develop will often persist for months or years. Similarly, drainage and/or pain may occur intermittently, or be continuous.

Early signs and symptoms:

When people first get hidradenitis suppurativa (HS), they often see:

  • One (or several) breakouts that look like pimples or boils.
  • Breakouts may stay on the skin; sometimes, they clear and reappear.

Later signs and symptoms:

Without treatment, HS can worsen. If this disease progresses, the person may develop:

  • Painful, deep breakouts that heal and reappear.
  • Breakouts that rupture and leak a foul-smelling fluid.
  • Scars that form as breakouts repeatedly heal and reappear.
  • Scars that become thicker with time.
  • Skin that begins to look spongy as tunnel-like tracts form deep in the skin.
  • Serious infections.

Signs and symptoms can change:

  • The signs and symptoms of HS can change quickly. One week, a person may have a foul-smelling fluid leaking from breakouts. The next week, the breakouts have cleared and scars are the only sign of HS.
  • Some people always have breakouts on their skin.

Skin cancer risk:

HS develops on skin that tends to get little or no direct sunlight. Yet, a few people have developed squamous cell carcinoma, a common type of skin cancer, where they had HS breakouts and scarring for years. Most cases developed in men who had long-standing HS on their genitals or around their anus.

Quality of life affected:

Without treatment, HS can continue its cycle of breakouts and healing. As the breakouts clear, scars form. Continual healing and scarring can cause hollow passages called fistulas to develop inside the body. Fistulas can be painful and require surgery to repair.


How do dermatologists diagnose Hidradenitis Suppurativa?

  • To diagnose this skin disease, a dermatologist looks closely at the skin and asks some questions.
  • If your breakouts are leaking fluid, your dermatologist may swab a bit of the fluid onto a slide to find out if you have an infection. You also may need a blood test.

How do dermatologists treat hidradenitis suppurativa?
Dermatologists offer patients who have hidradenitis suppurativa (HS) many treatment options, including many different medicines. Surgery may be an option when HS is severe or fails to respond to other treatment.
Treatment can help patients with HS:

  • Clear or reduce breakouts.
  • Get rid of scars and tunnels beneath the skin.
  • Prevent new breakouts.

Medicines used to treat HS: If you have HS, your dermatologist may include one or more of the following in your treatment plan:

  • Acne washes and medicines
  • Antibiotics
  • Bleach baths
  • Diabetes drug
  • Corticosteroid
  • Hormone therapy
  • Radiation therapy
  • Wound dressings
  • Biologics or bDMARDs
  • Surgical treatment

Lifestyle changes can be effective

Many people have HS for life. Studies continue to show that making certain lifestyle changes can help tremendously. Weight loss has proven so effective that some patients say maintaining a healthy weight prevents HS breakouts.