Hidradenitis Suppurativa: Symptoms, Causes, and Treatment Options

What is Hidradenitis Suppurativa?

Hidradenitis suppurativa, also known as acne inversa, is a long-term skin disease characterised by painful, inflamed lumps or abscesses that develop deep under the skin. These lumps typically appear in areas where skin rubs together, such as the armpits, groin, buttocks, and under the breasts. Over time, the lumps may break open, leak pus, and lead to scarring and the formation of tunnels (sinus tracts) beneath the skin.

According to the British Association of Dermatologists, hidradenitis suppurativa (HS) is not caused by poor hygiene or an infection; rather, it is thought to involve an abnormal immune response and inflammation in the hair follicles and sweat glands. While the exact cause remains unclear, several factors, including genetics, hormones, and lifestyle habits, are believed to play a role in the development of hidradenitis suppurativa.

Early Signs and Symptoms

• Blackheads appearing in pairs within small, pitted areas of skin
• Painful, pea-sized skin lumps that persist for weeks or months
• Bumps or sores that break open, draining pus and sometimes emitting an odour
• Tunnels (sinus tracts) under the skin that may drain blood and pus, healing slowly
• Localised pain, tenderness, and swelling in affected areas
• Occasional fatigue and itching preceding flare-ups

Stages of Hidradenitis Suppurativa (Hurley Staging System)

Hidradenitis suppurativa is classified into three stages based on the severity and extent of the disease:

1. Stage I (Mild): In this stage, individuals experience single or multiple abscesses without the formation of sinus tracts or scarring. The lesions are isolated and not connected, although they may recur in the same area.
2. Stage II (Moderate): As the condition progresses, recurrent abscesses develop alongside sinus tract formation and scarring. Lesions become more widespread and interconnected by tunnels beneath the skin, with involvement of multiple areas or wider spread within a single region.
3. Stage III (Severe): In the most severe stage, there is diffuse or nearly diffuse involvement, with multiple interconnected sinus tracts and abscesses spanning large areas. Extensive scarring and chronic drainage are present, often severely impacting mobility and quality of life.

Common Areas Affected

Hidradenitis suppurativa commonly affects skin folds and areas with many sweat glands, including:

• Armpits (axillae)
• Groin and inner thighs
• Buttocks and the cleft between them
• Under the breasts
• Perianal and genital regions
• Areas under waistbands, abdominal folds, and brassiere straps

Causes and Risk Factors

Hidradenitis suppurativa arises from inflammation and occlusion of hair follicles (not sweat glands), which subsequently trigger secondary inflammation involving nearby apocrine glands and surrounding tissues. While the precise mechanism is not fully clear, immune system dysfunction and genetic factors may play a role in its development.

• Family history of hidradenitis suppurativa
• Age (typically begins after puberty)
• Gender (more common in women)
• Smoking
• Obesity
• Hormonal factors (worse during menstrual periods)
• History of metabolic syndrome or other immune-related conditions

Complications of Hidradenitis Suppurativa

• Chronic pain and discomfort
• Scarring and skin changes
• Formation of tunnels (sinus tracts) under the skin
• Restricted movement due to pain and scarring
• Secondary skin infections
• Social isolation, depression, and low self-esteem
• Increased risk of developing other conditions (e.g., arthritis, Crohn's disease)
• Rarely, development of skin cancer in affected areas

How Hidradenitis Suppurativa is Diagnosed?

• Physical exam to assess painful nodules, abscesses, sinus tracts, and scarring
• Review of typical locations (armpits, groin, under breasts, buttocks)
• Patient history (onset after puberty, recurring symptoms, family history)
• No specific lab test is required; diagnosis is based on symptoms and clinical findings
• Hurley staging system to determine severity
• Sometimes, biopsies or cultures are used to rule out infection or other skin conditions

Treatment Options for Hidradenitis Suppurativa

Treatment depends on the severity of the condition and aims to manage symptoms, prevent new lesions, and reduce complications. Early diagnosis and intervention can improve outcomes. Hidradenitis suppurativa treatment options include:

• Medications to reduce inflammation, control infection, or modify the immune system
• Lifestyle changes and home remedies to reduce flare-ups and improve healing
• Surgical procedures for advanced or persistent cases

Medications for Hidradenitis suppurativa

• Topical antibiotics, such as clindamycin, to reduce bacterial growth and inflammation
• Oral antibiotics, such as tetracyclines (doxycycline, minocycline) for anti-inflammatory effects, or combination regimens like clindamycin with rifampin for refractory cases
• Corticosteroid injections to reduce swelling and pain in specific lesions
• Biologic drugs, such as adalimumab (FDA-approved for HS) and infliximab, target tumour necrosis factor-alpha (TNF-α), reducing chronic inflammation and lesion recurrence
• Hormonal therapy in select cases, particularly for women with menstrual cycle-related flares

Lifestyle and Home Remedies

• Maintaining a healthy weight to reduce skin friction and inflammation
• Wearing loose-fitting, breathable clothing to minimise irritation
• Practicing gentle skin hygiene, using non-irritating cleansers and moisturisers
• Quitting smoking, as it can exacerbate the symptoms
• Applying warm compresses to painful lumps for temporary relief
• Reducing skin friction in affected areas by avoiding tight clothing and using protective dressings

Surgical Procedures

• Incision and drainage of large, painful abscesses to provide temporary relief and prevent the spread of infection
• Unroofing (deroofing) tunnels to remove chronic tracts and promote healing
• Surgical removal of affected skin and tissue in severe or persistent cases
• Laser therapy to remove hair follicles and reduce the likelihood of future flares
• Skin grafting in severe cases with extensive tissue damage and scarring

Living with Hidradenitis Suppurativa

Living with hidradenitis suppurativa can be challenging, as the condition often significantly impacts quality of life due to chronic pain, scarring, and recurrent flares. Many people with hidradenitis suppurativa symptoms may need to adapt their daily routines to include frequent wound care, dressing changes, and pain management. The emotional distress and social withdrawal associated with hidradenitis suppurativa can be substantial, and seeking counselling or joining support groups may be beneficial.

Integrated care with dermatologists, pain specialists, and mental health professionals is often recommended to address the various aspects of living with hidradenitis suppurativa. By working closely with healthcare providers and adopting lifestyle changes, individuals can better manage their hidradenitis suppurativa symptoms and improve their overall well-being.

When to See a Doctor?

• Persistent, painful lumps that don't improve in a few weeks
• Difficulty moving due to pain or scarring
• Frequent recurrence of lesions
• Abscesses appearing in multiple locations
• Flares that are severe or often
• Signs of infection (fever, spreading redness)

Prevention Tips

• Avoid skin friction wherever possible by wearing loose, comfortable clothing
• Maintain a healthy weight through a balanced diet and regular exercise
• Quit smoking, as it can worsen hidradenitis suppurativa symptoms
• Practice good hygiene and gentle skin care, using mild, fragrance-free products
• Wear loose, breathable clothing made from natural fibres like cotton
• Seek early treatment for any new skin changes or lumps

Conclusion

Hidradenitis suppurativa is a chronic, inflammatory skin condition that can cause significant pain, scarring, and emotional distress. Early diagnosis and multidisciplinary management are crucial for controlling symptoms, preventing complications, and improving quality of life. Treatment options include medications, lifestyle adjustments, and surgery, tailored to the severity of the condition and individual needs. Ongoing support and education are essential for managing the physical and emotional challenges associated with HS.

At Metropolis Healthcare, we understand the importance of accurate diagnosis and personalised care in managing chronic conditions like hidradenitis suppurativa. With a network of over 220 laboratories, 4600+ service centres, and more than 10,000 touchpoints across 750+ towns in India, Metropolis offers a comprehensive range of over 4,000 diagnostic tests and profiles. Our team of qualified blood collection technicians provides convenient at-home sample collection services, ensuring a comfortable and hassle-free experience for our patients. By delivering reliable results and patient-centric care, Metropolis Healthcare is committed to empowering individuals to prioritise their health and well-being.

FAQs

Is Hidradenitis suppurativa contagious?

No, hidradenitis suppurativa is not contagious. It cannot be spread from person to person through contact or sharing personal items. Hidradenitis suppurativa is a chronic inflammatory condition that develops due to a combination of genetic, hormonal, and environmental factors, not due to an infection or poor hygiene.

Can Hidradenitis suppurativa be completely cured?

Currently, there is no known cure for hidradenitis suppurativa. While treatments can help manage symptoms and reduce flares, the condition is usually chronic and lifelong. The goal of treatment is to minimise pain, prevent complications, and improve quality of life. With proper care and management, many people with hidradenitis suppurativa can achieve long periods of remission and better control over their symptoms.

What foods trigger Hidradenitis suppurativa?

No specific diet has been universally proven to prevent hidradenitis suppurativa. However, some individuals report symptom improvement when avoiding high-glycaemic foods, dairy, and brewer’s yeast. Evidence remains limited and varies by person. Keeping a food diary and working with a doctor or nutritionist can help identify potential triggers and guide dietary modifications.

Does losing weight help with Hidradenitis suppurativa?

Yes, weight loss can reduce the severity and frequency of hidradenitis suppurativa flares, especially for overweight individuals. Excess weight can exacerbate skin friction and inflammation, worsening hidradenitis suppurativa symptoms. Maintaining a healthy weight through a balanced diet and regular exercise is recommended as part of a comprehensive management plan.

Which doctor should I consult for Hidradenitis suppurativa symptoms?

If you suspect you have hidradenitis suppurativa, it's best to consult a dermatologist experienced in treating the condition. Dermatologists are skin specialists who can provide the right diagnosis in this case, assess its severity, and develop an individualised treatment plan. In severe cases, a multidisciplinary team including surgeons, pain specialists, and mental health professionals may be involved to provide comprehensive care.

References

1. https://my.clevelandclinic.org/health/diseases/17716-hidradenitis-suppurativa
2. https://www.bad.org.uk/pils/hidradenitis-suppurativa
3. https://www.nhs.uk/conditions/hidradenitis-suppurativa/
4. https://www.aad.org/public/diseases/a-z/hidradenitis-suppurativa-symptoms
5. https://www.ncbi.nlm.nih.gov/books/NBK534867/