Hidradenitis Suppurativa: Complete Symptoms & Treatment Guide

Authoritative facts about the skin condition hidradenitis suppurativa from DermNet New Zealand, covering symptoms, causes, diagnosis, treatment, and more.

What is hidradenitis suppurativa?

Hidradenitis suppurativa (HS), also known as acne inversa, is a chronic inflammatory skin condition characterized by recurrent, painful nodules, abscesses, and sinus tracts primarily affecting apocrine gland-bearing areas such as the axillae, groin, perineum, and inframammary regions. It leads to scarring and can significantly impair quality of life due to pain, drainage, odor, and disfigurement. HS affects approximately 1% of the population, predominantly women, with onset typically in young adulthood between ages 20 and 40. The condition is not contagious and arises from a complex interplay of genetic, hormonal, immunological, and environmental factors.

Who gets hidradenitis suppurativa?

HS is more common in females (3:1 ratio) and individuals of African descent. Risk factors include family history (up to 40% familial cases), obesity, smoking, metabolic syndrome, and conditions like Crohn’s disease, polycystic ovary syndrome (PCOS), and diabetes. It rarely occurs before puberty or after menopause, suggesting hormonal influences. Early intervention in at-risk groups can mitigate severity.

What causes hidradenitis suppurativa?

The exact cause remains unclear, but HS involves follicular occlusion leading to inflammation, bacterial overgrowth, and biofilm formation rather than a primary infection. Key contributors include:

• Genetic predisposition: Mutations in genes like gamma-secretase complex (nicastrin, PSENEN) identified in familial cases.
• Immune dysregulation: Overactive Th1/Th17 pathways with elevated TNF-alpha, IL-17, and IL-1.
• Hormonal factors: Androgen sensitivity and progesterone fluctuations.
• Lifestyle triggers: Smoking (70-90% of patients), obesity (increased mechanical friction), and excessive sweating.
• Microbiome alterations: Dysbiosis with staphylococci and anaerobes in lesions.

These factors culminate in dilated hair follicles that rupture, spilling contents into dermis and forming abscesses and tunnels.

What are the clinical features of hidradenitis suppurativa?

HS progresses through stages with characteristic lesions:

• Early (Stage I): Comedones, painful pea-sized nodules that resolve or form abscesses.
• Moderate (Stage II): Recurrent abscesses with sinus tracts and comedones, moderate scarring.
• Severe (Stage III): Interconnected tracts, extensive fibrosis, contractures limiting movement.

Symptoms include burning, stinging, hyperhidrosis 12-48 hours pre-lesion; painful lumps bursting with purulent, foul-smelling discharge; chronic pain; pruritus; and fatigue. Common sites: axillae (70%), groin (60%), buttocks (40%), breasts, perianal area. Complications encompass anemia, hypoalbuminemia, squamous cell carcinoma (rare), and lymphedema.

How is hidradenitis suppurativa diagnosed?

Diagnosis is clinical, based on history of recurrent boils in intertriginous areas lasting >6 months, excluding infection or folliculitis decalvans. Hurley staging guides assessment:

Biopsy may confirm if atypical; ultrasound/MRI detects subclinical tracts; swab cultures guide antibiotics. Differential includes carbuncles, Crohn’s, tuberculosis.

What is the treatment of hidradenitis suppurativa?

No cure exists; treatment is stage-tailored, multimodal, aiming to control inflammation, eradicate bacteria, relieve pain, and prevent progression. Early diagnosis improves outcomes.

General measures

• Weight loss (5-10% reduces flares).
• Smoking cessation (halves severity).
• Wear loose clothing; use antibacterial washes (chlorhexidine).
• Absorbent dressings for drainage; pain relief (paracetamol, NSAIDs).

Localized treatments

• Intralesional corticosteroids for nodules.
• Topical clindamycin, resorcinol 15% cream.
• Laser hair removal (Nd:YAG, alexandrite) reduces recurrence by 70%.

Systemic medications

Antibiotics: Clindamycin + rifampicin (300mg BD each, 12 weeks); tetracyclines (doxycycline 100mg OD).

Anti-inflammatories: Oral corticosteroids short-term; dapsone.

Hormonal: Ethinyloestradiol + cyproterone acetate; spironolactone; metformin for PCOS.

Biologics: Adalimumab (FDA-approved, 40mg weekly after loading); secukinumab promising.

Surgical interventions

• Incision/drainage (acute abscesses, temporary relief).
• Deroofing/unroofing (moderate HS, low recurrence).
• Wide excision + reconstruction (severe, refractory cases).
• CO2 laser ablation (effective for mild-moderate).

Complications of hidradenitis suppurativa

Severe HS causes extensive scarring, restricted mobility, chronic pain, anemia, depression (30-50% prevalence), squamous cell carcinoma (3.7% lifetime risk in perianal disease), and fistulae to bowel/bladder. Multidisciplinary care addresses comorbidities like obesity, IBD, spondyloarthropathy.

What is the outcome for hidradenitis suppurativa?

HS is lifelong but manageable; mild cases remit post-menopause. Severe disease persists, with 50% progression over 20 years without treatment. Remission rates: 20-50% with aggressive therapy. Quality of life improves with weight loss/smoking cessation (50% reduction in flares).

Prevention of hidradenitis suppurativa flares

• Maintain BMI <25.
• Avoid smoking/depilatories.
• Daily antiseptic washes; loose cotton clothing.
• Prophylactic antibiotics post-remission.

HS support groups

Global organizations like HS Foundation, UK Hidradenitis Suppurativa Trust offer forums, events. Dermatologist referral to specialists essential.

Frequently asked questions about hidradenitis suppurativa

Is hidradenitis suppurativa an infection?

No, HS is inflammatory, not primarily infectious; bacteria are secondary.

Does hidradenitis suppurativa smell?

Yes, purulent drainage from tracts causes odor; managed with hygiene.

Can hidradenitis suppurativa be cured?

No cure, but treatments control it effectively.

Does hidradenitis suppurativa cause cancer?

Rarely; 3.7% risk of squamous cell carcinoma in chronic perianal HS.

Is hidradenitis suppurativa hereditary?

30-40% familial; genetic mutations implicated.

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