Hidradenitis Suppurativa: Symptoms, Causes, and Treatment Options

Introduction

Hidradenitis suppurativa (HS) is a chronic skin condition that leads to painful lumps beneath the skin, typically in areas where skin rubs together, such as the armpits, groin, and under the breasts. These lumps can become inflamed, infected, and may eventually rupture, resulting in scarring. First identified in the 19th century, HS has historically been misunderstood and underdiagnosed. However, recent advances in medical research have significantly improved our understanding of the condition.

This article offers a comprehensive overview of Hidradenitis suppurativa, covering its risk factors, symptoms, diagnostic tests, treatment options (including medications and procedures), and self-care strategies. By gaining a better understanding of the condition, patients can collaborate with their healthcare providers to create a personalized treatment plan that enhances their quality of life.

Definition of Hidradenitis Suppurativa

Hidradenitis suppurativa is a chronic skin disorder characterized by painful lumps and abscesses, often in areas where skin rubs together. This article will explore its risk factors, symptoms, diagnostic tests, medications, procedures, and home care strategies.

Description of Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a long-term inflammatory skin condition that affects hair follicles, particularly in areas where skin folds or rubs together, such as the armpits, groin, buttocks, and under the breasts. HS typically starts with small, painful lumps that resemble pimples or boils. Over time, these lumps can enlarge, become inflamed, and may rupture, releasing pus. This can lead to the formation of tunnels under the skin, known as sinus tracts, and result in scarring.

The progression of HS varies from person to person. Some individuals may experience mild symptoms with occasional flare-ups, while others may have more severe, chronic symptoms that significantly impact daily life. If left untreated, the condition tends to worsen over time, with more frequent and severe flare-ups.

HS is relatively uncommon, affecting approximately 1-4% of the population. It is more prevalent in women than men and often begins after puberty, typically in the late teens or early twenties. While the exact cause of HS is not fully understood, it is believed to be related to inflammation of the hair follicles and dysfunction of the immune system. Early diagnosis and treatment are essential for managing symptoms and preventing complications such as scarring and infection.

Risk Factors for Developing Hidradenitis Suppurativa

Lifestyle Risk Factors

Certain lifestyle factors can increase the risk of developing Hidradenitis suppurativa. One of the most significant risk factors is smoking. Research shows that individuals who smoke are more likely to develop HS, and smoking can also worsen the severity of the condition. Quitting smoking may help reduce the frequency and intensity of flare-ups.

Obesity is another important lifestyle risk factor. Excess weight can lead to increased friction in areas where skin rubs together, such as the armpits and groin, which can trigger or worsen HS symptoms. Maintaining a healthy weight through diet and exercise may help reduce the risk of developing HS or lessen the severity of symptoms in those who already have the condition.

Poor hygiene or wearing tight clothing that causes friction can also contribute to the development of HS. While these factors alone do not cause the condition, they can irritate the skin and exacerbate symptoms.

Medical Risk Factors

Several medical conditions are associated with an increased risk of developing Hidradenitis suppurativa. Individuals with metabolic syndrome, which includes conditions such as high blood pressure, high cholesterol, and insulin resistance, are more likely to develop HS due to the underlying inflammation associated with metabolic syndrome.

Polycystic ovary syndrome (PCOS) is another medical condition linked to HS. Women with PCOS often have hormonal imbalances, which may contribute to the development of HS. Additionally, individuals with Crohn’s disease, an inflammatory bowel disease, are at a higher risk of developing HS, as both conditions involve chronic inflammation.

Other medical conditions that may increase the risk of HS include diabetes and autoimmune disorders. These conditions can affect the immune system and contribute to the chronic inflammation seen in HS.

Genetic and Age-Related Risk Factors

Genetics also play a role in the development of Hidradenitis suppurativa. Studies show that up to one-third of individuals with HS have a family history of the condition, suggesting a genetic predisposition, although the exact genes involved are not yet fully understood.

Age is another important factor. HS typically begins after puberty, with most cases developing between the ages of 18 and 30. The condition is rare in children and older adults. Hormonal changes during puberty may trigger the onset of HS, which is why the condition often starts in adolescence or early adulthood.

While HS can affect individuals of all races and ethnicities, some studies suggest it may be more common in individuals of African descent. However, more research is needed to fully understand the relationship between race and HS risk.

Clinical Manifestations of Hidradenitis Suppurativa

Painful Lumps

Painful lumps, also known as nodules, are one of the earliest and most common symptoms of Hidradenitis suppurativa (HS), occurring in nearly all patients. These lumps typically develop in areas where skin rubs together, such as the armpits, groin, and under the breasts. The lumps are caused by inflammation of the hair follicles and surrounding tissue, leading to swelling and tenderness. As the disease progresses, these lumps can become more frequent and severe, especially during flare-ups. In the early stages, the lumps may be small and firm, but over time, they can grow larger and more painful.

Abscesses

Abscesses, or collections of pus under the skin, occur in about 70-80% of HS patients. These abscesses develop when blocked hair follicles become infected, leading to pus-filled pockets. Abscesses are often painful and can rupture, releasing pus and causing further inflammation. They are more common in the later stages of the disease and can recur in the same areas, leading to chronic pain and discomfort. Abscesses can also result in scarring and the formation of skin tunnels (sinus tracts) if left untreated.

Drainage of Pus

Drainage of pus is a hallmark symptom of HS, affecting around 60-70% of patients. This occurs when abscesses or nodules rupture, releasing thick, foul-smelling pus. The drainage can be persistent and may lead to secondary infections if not properly managed. The presence of pus indicates the body is attempting to fight off an infection within the blocked hair follicles. Drainage is often accompanied by pain, swelling, and inflammation, significantly impacting a patient’s quality of life due to the associated odor and discomfort.

Scarring

Scarring is a common long-term consequence of HS, affecting approximately 50-60% of patients. As the disease progresses, repeated inflammation, abscess formation, and drainage can lead to the destruction of skin tissue. This results in thick, fibrous scars, particularly in areas where abscesses have ruptured. Scarring can cause the skin to become tight and less flexible, leading to discomfort and restricted movement. In severe cases, scarring can also contribute to the formation of skin tunnels, further complicating the condition.

Skin Tunnels (Sinus Tracts)

Skin tunnels, also known as sinus tracts, develop in about 30-40% of HS patients, particularly in the later stages of the disease. These tunnels form when abscesses repeatedly rupture and heal, creating channels under the skin that connect different areas of inflammation. Sinus tracts can be painful and may continue to drain pus, even after the initial abscess has healed. They are a sign of chronic, severe HS and can lead to further complications, such as secondary infections and extensive scarring.

Inflammation

Inflammation is a key feature of HS and is present in nearly all patients. The condition is characterized by chronic inflammation of the hair follicles and surrounding skin tissue, leading to redness, swelling, and pain. Inflammation is often triggered by blockages in the hair follicles, which can be exacerbated by friction, sweating, and bacterial infections. Over time, the inflammation can become more widespread, affecting larger areas of the skin and contributing to the development of abscesses, nodules, and scarring.

Itching

Itching, or pruritus, affects around 30-40% of HS patients. Itching is often a result of the inflammation and irritation caused by blocked hair follicles and abscess formation. The skin may become dry, flaky, and irritated, leading to persistent itching. Scratching the affected areas can worsen the condition by causing further damage to the skin and increasing the risk of infection. Itching is more common in the early stages of the disease but can persist as the condition progresses.

Odor

Odor is a distressing symptom for many HS patients, affecting approximately 50-60% of individuals. The foul smell is primarily caused by the drainage of pus from abscesses and sinus tracts. The pus contains bacteria and dead skin cells, which produce a strong, unpleasant odor. The odor can be difficult to manage and may lead to social embarrassment and isolation. Proper wound care and hygiene are essential to reduce the risk of infection and minimize the odor associated with HS.

Flare-Ups

Flare-ups, or periods of increased disease activity, are common in HS and can occur in up to 80% of patients. Flare-ups are characterized by the sudden appearance of new painful lumps, abscesses, and inflammation. They can be triggered by factors such as stress, hormonal changes, heat, and friction. Flare-ups can last for days or weeks and may require medical intervention to manage the symptoms. During a flare-up, patients may experience increased pain, drainage, and discomfort, making it difficult to perform daily activities.

Hyperpigmentation

Hyperpigmentation, or darkening of the skin, occurs in about 40-50% of HS patients. This condition is caused by repeated inflammation and damage to the skin, leading to an overproduction of melanin, the pigment responsible for skin color. Hyperpigmentation is more common in individuals with darker skin tones and tends to occur in areas where abscesses and nodules have healed. While hyperpigmentation is not harmful, it can be a cosmetic concern for many patients and may contribute to feelings of self-consciousness.

Diagnostic Evaluation of Hidradenitis Suppurativa

The diagnosis of Hidradenitis suppurativa (HS) is primarily based on a thorough physical examination and patient history. A healthcare provider will assess the characteristic symptoms of HS, such as painful lumps, abscesses, and scarring, and ask about the frequency and duration of flare-ups. The provider will also examine the affected areas of the skin, looking for signs of inflammation, drainage, and skin tunnels. In some cases, additional diagnostic tests may be necessary to rule out other conditions and confirm the diagnosis of HS.

Skin Biopsy

Test Information: A skin biopsy involves removing a small sample of skin tissue from the affected area for examination under a microscope. This test is typically performed in a healthcare provider’s office using local anesthesia to numb the area. The biopsy sample is then sent to a laboratory, where a pathologist examines it for signs of inflammation, infection, and other abnormalities. A skin biopsy is important in diagnosing HS because it can help differentiate the condition from other skin disorders, such as cystic acne, folliculitis, or skin infections.

Results that Indicate Hidradenitis Suppurativa: In patients with HS, a skin biopsy may reveal chronic inflammation, the presence of sinus tracts, and the destruction of hair follicles. These findings are consistent with the characteristic features of HS. If the biopsy results show these changes, it can confirm the diagnosis of HS. However, if the biopsy does not show these findings, it may suggest that another condition is causing the symptoms. In such cases, the healthcare provider may recommend additional tests or refer the patient to a specialist for further evaluation.

Imaging Studies

Test Information: Imaging studies, such as ultrasound, MRI, or CT scans, can be used to assess the extent of HS and identify complications, such as abscesses, sinus tracts, and scarring. Ultrasound is a non-invasive imaging technique that uses sound waves to create images of the skin and underlying tissues. MRI and CT scans provide more detailed images and can help evaluate the depth and severity of the inflammation. These imaging studies are particularly useful in advanced cases of HS, where the condition may involve deeper tissues and structures.

Results that Indicate Hidradenitis Suppurativa: Imaging studies in patients with HS may show thickened skin, fluid-filled abscesses, and the presence of sinus tracts. These findings are consistent with the chronic inflammation and tissue damage seen in HS. If imaging studies reveal these changes, it can help confirm the diagnosis and guide treatment decisions. However, if the imaging results are normal, it may suggest that the condition is in its early stages or that another condition is causing the symptoms. In such cases, further evaluation may be necessary.

Blood Tests

Test Information: Blood tests are not typically used to diagnose HS directly, but they can help assess the overall health of the patient and identify any underlying conditions that may be contributing to the symptoms. Common blood tests include a complete blood count (CBC), which measures the levels of different blood cells, and tests for markers of inflammation, such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). These tests can provide valuable information about the body’s immune response and the presence of infection or inflammation.

Results that Indicate Hidradenitis Suppurativa: In patients with HS, blood tests may show elevated levels of inflammatory markers, such as CRP and ESR, indicating the presence of chronic inflammation. However, these findings are not specific to HS and can be seen in other inflammatory conditions. If blood tests show signs of infection, such as an elevated white blood cell count, it may suggest that the patient has a secondary infection related to HS. If the blood test results are normal, it does not rule out HS, but it may prompt the healthcare provider to consider other potential causes of the symptoms.

Culture Tests

Test Information: A culture test involves collecting a sample of pus or fluid from an abscess or draining lesion and sending it to a laboratory to identify any bacteria or other microorganisms present. This test is important in HS because it can help determine if a secondary bacterial infection is contributing to the symptoms. The culture test is typically performed by swabbing the affected area or using a needle to aspirate fluid from an abscess. The sample is then incubated in a laboratory to allow any bacteria to grow, and the results are usually available within a few days.

Results that Indicate Hidradenitis Suppurativa: In patients with HS, culture tests may reveal the presence of bacteria, such as Staphylococcus aureus or Streptococcus species, which are common causes of secondary infections in HS lesions. If a bacterial infection is identified, the healthcare provider may prescribe antibiotics to treat the infection and reduce inflammation. However, the presence of bacteria does not confirm the diagnosis of HS, as bacterial infections can occur in other skin conditions as well. If the culture test is negative, it suggests that the symptoms are not due to a bacterial infection, but it does not rule out HS.

What if All Tests are Negative but Symptoms Persist?

If all diagnostic tests come back negative but you continue to experience symptoms such as painful lumps, abscesses, and drainage, it is important to follow up with your healthcare provider. They may recommend additional testing or refer you to a dermatologist or specialist who has experience with HS. In some cases, a diagnosis of HS can be made based on clinical symptoms alone, especially if the characteristic features of the disease are present. Your healthcare provider will work with you to develop a treatment plan that addresses your symptoms and improves your quality of life.

Treatment Options for Hidradenitis Suppurativa

Medications for Hidradenitis Suppurativa

Adalimumab

Adalimumab is a biologic medication that targets tumor necrosis factor-alpha (TNF-alpha), a protein involved in inflammation. By reducing inflammation, it helps alleviate the symptoms of Hidradenitis Suppurativa (HS).

Typically prescribed for moderate to severe HS, especially when other treatments have not been effective, Adalimumab is administered via injection under the skin, usually on a weekly or biweekly basis. It is often considered a first-line biologic treatment for HS.

Many patients experience a reduction in flare-ups and symptom severity within a few months of starting treatment.

Infliximab

Infliximab is another biologic that targets TNF-alpha to reduce inflammation. It is often used for severe HS cases that have not responded to other treatments.

Administered through intravenous (IV) infusion, typically in a hospital or clinic setting, Infliximab is generally reserved for advanced HS or when Adalimumab is ineffective.

Patients may notice improvements in symptoms within weeks to months, including reduced inflammation and fewer abscesses.

Antibiotics

Antibiotics are commonly prescribed to treat infections associated with HS, helping to control bacterial growth and reduce inflammation.

Depending on the severity of the infection, antibiotics may be given in topical or oral forms. They are often used in the early stages of HS or during flare-ups to manage infection and inflammation.

Patients can expect a reduction in pain, swelling, and infection within days to weeks of starting antibiotic therapy.

Corticosteroids

Corticosteroids are anti-inflammatory medications that help reduce swelling and pain in HS lesions by suppressing the immune system’s inflammatory response.

They may be applied topically, injected directly into lesions, or taken orally. Corticosteroids are typically used for short-term relief during flare-ups or in cases of severe inflammation.

While patients may experience rapid relief, long-term use is generally avoided due to potential side effects.

Clindamycin

Clindamycin is an antibiotic used either topically or orally to treat bacterial infections in HS. It works by reducing bacteria on the skin and decreasing inflammation.

Topical clindamycin is commonly prescribed for mild to moderate HS, while oral clindamycin may be used for more severe infections. It is often combined with other treatments, such as rifampin, for enhanced effectiveness.

Patients may notice a reduction in lesion size and number within a few weeks of consistent use.

Dapsone

Dapsone is both an anti-inflammatory and antibiotic medication used to treat HS by reducing inflammation and bacterial growth.

Typically prescribed for mild to moderate HS, Dapsone is taken orally and may be combined with other medications when other treatments have not been successful.

Patients may experience gradual symptom improvement over several weeks to months.

Methotrexate

Methotrexate is an immunosuppressive medication that reduces inflammation by inhibiting the immune system. It is often used in more severe cases of HS.

Administered either orally or by injection, Methotrexate is typically reserved for patients who have not responded to other treatments, including biologics. It helps control chronic inflammation and prevent new lesions from forming.

Symptom reduction may take several weeks to months, and regular monitoring is required due to potential side effects.

Retinoids

Retinoids, which are derivatives of vitamin A, help regulate skin cell turnover and reduce inflammation. They are sometimes used to treat HS.

Typically prescribed for mild to moderate HS, especially when acne-like lesions are present, retinoids are taken orally and may be combined with other treatments.

Patients may notice skin improvements over several weeks to months, though side effects such as dry skin and increased sensitivity to sunlight can occur.

Biologics

Biologics are medications that target specific parts of the immune system to reduce inflammation. Adalimumab and Infliximab are examples of biologics used to treat HS.

These medications are generally reserved for moderate to severe HS cases that have not responded to other treatments. Biologics are administered via injections or infusions and require regular monitoring by a healthcare provider.

Patients can expect a reduction in the frequency and severity of flare-ups, though it may take several months to see significant improvements.

Procedures for Hidradenitis Suppurativa

Incision and Drainage

Incision and drainage is a minor surgical procedure used to relieve pain and pressure from HS abscesses by draining pus.

This procedure is typically performed during a flare-up when an abscess becomes large and painful. While it provides immediate relief, it does not prevent future flare-ups.

Patients can expect immediate pain relief, though abscesses may recur if the underlying inflammation is not controlled.

Excision

Excision involves surgically removing affected skin and tissue in areas where HS lesions are recurrent or severe.

This procedure is usually reserved for advanced HS cases where other treatments have failed. The affected area is removed, and the wound is either stitched closed or left to heal naturally.

Patients can expect significant symptom reduction in the treated area, though new lesions may develop elsewhere.

Skin Grafting

Skin grafting is a surgical procedure in which healthy skin is transplanted to cover areas where HS lesions have been excised.

Typically used alongside excision for severe HS cases, skin grafting promotes healing and reduces scarring.

Patients can expect improved healing and reduced scarring, though recovery may take several weeks.

Laser Therapy

Laser therapy uses focused light to destroy hair follicles and reduce inflammation in areas affected by HS.

This procedure is often used for mild to moderate HS, particularly in areas where hair follicles contribute to lesion formation. Multiple sessions may be required for optimal results.

Patients can expect fewer flare-ups and lesions over time, though it may take several months to see significant improvements.

Improving Hidradenitis Suppurativa and Seeking Medical Help

In addition to medical treatments, several home remedies can help manage Hidradenitis Suppurativa symptoms and improve quality of life:

1. Warm compresses: Applying warm compresses to affected areas can reduce pain and promote abscess drainage.
2. Maintaining a healthy weight: Excess weight can increase friction and sweating, which may worsen HS symptoms.
3. Wearing loose-fitting clothing: Tight clothing can irritate the skin and trigger flare-ups. Opt for loose, breathable fabrics.
4. Avoiding triggers: Identifying and avoiding personal triggers, such as certain foods or stress, can help reduce flare-ups.
5. Keeping the skin clean: Regularly washing affected areas with antibacterial soap can help prevent infections.
6. Applying topical antiseptics: Using antiseptic creams or ointments can reduce bacteria and prevent infections.
7. Managing stress: Stress can trigger flare-ups, so practicing stress-reduction techniques like meditation or yoga may help.
8. Quitting smoking: Smoking is a known HS trigger, so quitting can significantly reduce the frequency and severity of flare-ups.

Telemedicine offers a convenient way to manage HS from home. Through virtual consultations, you can discuss symptoms, receive prescriptions, and get advice on managing flare-ups without needing to visit a clinic. If symptoms worsen or new complications arise, seek medical help promptly.

Living with Hidradenitis Suppurativa: Tips for Better Quality of Life

Living with HS can be challenging, but proactive treatment, a healthy lifestyle, and support from healthcare providers and support groups can make a significant difference. Regular follow-ups, whether in-person or via telemedicine, can help you stay on top of your condition and adjust treatment as needed.

Conclusion

Hidradenitis Suppurativa is a chronic skin condition that can significantly impact your quality of life. Early diagnosis and treatment are crucial for managing symptoms and preventing complications. By working closely with a healthcare provider, you can develop a personalized treatment plan that includes medications, procedures, and lifestyle changes to control flare-ups and improve your overall well-being.

If you’re living with HS, our telemedicine practice is here to help. Schedule a virtual consultation with one of our primary care providers to discuss your symptoms and explore treatment options tailored to your needs.

James Kingsley

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