Hidradenitis Suppurativa

What is hidradenitis suppurativa?

Hidradenitis suppurativa (HS), also known as "Acne Inversa," is a chronic inflammatory skin condition that can occur after puberty. First described in 1839, HS is not contagious but can be painful. It usually develops in areas where there is skin-to-skin contact, such as armpits, the top of the inner thigh, the groin and under the breasts, etc. It can also develop around hair follicles where scent (apocrine) sweat glands or oil (sebaceous) ducts are found. Similar to acne, which is a disease of the oil ducts, the inflammation in HS may be associated with infection, which, in turn, may cause pus to form.

There are three clinical stages of HS:

• Stage 1: The formation of single or multiple areas of inflammation and pus (abscesses), without sinus tracts (tunnels under the skin) and scar formation (cicatrisation).


• Stage 2: Single or multiple abscesses recur, possibly at widely separated areas of the body. Sinus tracts form and there is scarring.


• Stage 3: Multiple abscesses develop across an entire area of the body. Sinus tracts may connect otherwise separate abscesses.

Currently, HS is believed to be uncommon. It is slightly more prevalent in African-Americans and women. However, it may be more common than statistics show. Some people may be hesitant to talk to their doctor about HS because they feel shame or are embarrassed by their condition. Others with HS may not be accurately diagnosed because HS can look like other conditions.

Because depression is common among people who live in chronic pain, it is not surprising that as many as 80 percent of all HS sufferers are diagnosed as clinically depressed.

What causes hidradenitis suppurativa?

To date, there is no known cause of hidradenitis suppurativa (HS). It develops when sweat (apocrine) glands become clogged, either by perspiration or because incomplete development makes it difficult for them to drain properly. The trapped fluids are then forced into the surrounding tissue, causing inflammation and infection. Poor hygiene does not cause HS.

There is a genetic predisposition toward developing HS. People who have acne, also genetically predisposed, are more likely to develop HS. Individuals with tightly curled hair, such as those of African ancestry, are at an increased risk of developing HS. And ingrown hairs can predispose someone to developing HS, as well.

Although obesity does not cause HS, it can make it worse. Stress, the onset of the menstrual period, extreme heat or excessive perspiration can also increase symptoms.

What are the symptoms of hidradenitis suppurativa?

One reason hidradenitis suppurativa (HS) is most likely under-diagnosed is that it can look like other conditions, such as boils, carbuncles or skin infections. It is painful and can be disabling. It is rarely fatal, except when an overwhelming systemic infection develops in an immunocompromised person.

HS symptoms can take several forms:

• Single or multiple areas of inflammation and pus (abscesses), similar to acne in appearance.


• Non-inflamed, hard lumps under the skin that are very painful to the touch and may persist for years. These lumps have the potential to become inflamed, and, in some people with HS, they can get as large as a baseball.


• Painful, rounded deep-rooted inflamed lumps. These sores heal slowly or not at all, causing scarring. They can also chronically seep fluid, leading to the development of sinus tracts, or tunnels under the skin. This, in turn can lead to further inflammation and lumps. Bacterial infection is also possible.

In rare cases, the condition can be extensive, preventing a person from performing normal work functions or engaging in normal social activities.

How is hidradenitis suppurativa treated?

There is no known cure for hidradenitis suppurativa (HS), but the symptoms can be lessoned with various treatments. Several options have been found to be helpful in some cases.

In mild cases, or in addition to other treatments for more severe cases, patients have found it helpful to:

• Reduce the presence of bacteria on the skin by applying topical antibiotics, antiseptics or acne preparations.


• Wear loose clothing to prevent skin irritation.


• Loose weight to reduce the number of areas where there is skin-to-skin contact.

In more serve cases, treatment options include:

• Oral antibiotics, such as flucloxacillin, dicloxacillin, clindamycin or rifampicin, which may be prescribed to reduce bacterial infection.


• Tetracycline or metronidazole, which may be prescribed to reduce inflammation.


• Sometimes surgery is necessary to drain infected areas or remove scarred tissue. Surgery is reserved for only very severe cases.

In cases affecting women, a trial of the oral contraceptive pill for a year or more has helped. Supplementing with vitamin A derivatives (oral retinoids) - especially isotretinoin - for six months to a year, has proven effective for acne and may also be helpful in relieving symptoms of HS.