Multiple lesions with inflammation, drainage and scarring.
Multiple lesions with inflammation, drainage and scarring.
Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the intertriginous skin areas, where hyperkeratinization of the epithelium causes pathologic hair follicle occlusion, with subsequent dilation and rupture. It is sometimes called “acne inversa,” although it is different from acne. HS is 2-4 times more common in females. It is also more common in African Americans. Onset is generally after puberty and most common between 20-24 years of age.
The lesions of HS usually start as a single inflamed, painful, raised nodule. The nodule either slowly disappears (between 10 and 30 days) or opens up, draining pus. Eventually, healing occurs but a scar may remain.
The patient is usually a woman with inflammatory nodules of the axilla and/or groin that may rupture, drain, and cause scarring. Some patients have more comedonal disease, others inflammatory nodules, and others erosive lesions. The perianal and inframammary areas are commonly affected as well. Sinuses, fistulas, and scars accumulate over time. Lesions are often quite painful or sore. Primary lesions are sterile but staphylococcal or other bacteria commonly infect secondarily. Rarely, a squamous cell carcinoma may develop in the setting of chronic HS. Chronic anemia may be associated and can cause chronic fatigu.
Patients with HS, and particularly women, experience great distress in their sex life. Embarrassment, frustration, and sadness are common. Asking a simple question about sexual satisfaction allows the patient, if she desires, to open up and express these feelings and may lead to better treatment approaches [JAAD Sept 2012].
Metabolic syndrome (MeS) combines obesity, dyslipidemia, hyperglycemia, and hypertension and is correlated with an increased risk for the development of cardiovascular disease. In one study of HS [JAAD April 2014], the prevalence of MeS was 50%.
Potential complications include keloid scars, fistulas, lymphedema, SCC, anemia of chronic disease, amyloid of the skin and/or kidney with the development of nephrotic syndrome, scarring, and limb contractures.
Patients with HS may develop systemic inflammatory response syndrome (SIRS) which is an exaggerated defense response of the body to a noxious stressor in an attempt to localize and then eliminate the endogenous or exogenous source of the insult. HS patients who present with sepsis-like features including tachycardia and leukocytosis should be considered for admission.
Cancer, in particular anogenital SCC may rarely occur [JAAD 2019;80;808]. The typical patient is one with long term, severe disease who develops a very painful nodule or lesion, often in the perianal or perineal area.
See the patient handout
Bacterial cultures may occasionally be done to rule out other causes or secondary infection.
Pain management, mental health counseling/support and local wound care and symptom relief should be addressed with all patients.
Like acne the goal for treatment of HS should be to achieve as much disease control as early as possible to prevent significant scarring and sinus tract formation, which can often lead to significant recalcitrant disease.
Treatment of inflammatory nodules early (e.g., within several days) with intralesional steroids (e.g., TMC 5-10 mg/cc) can give the patient great relief. In one study utilizing triamcinolone 10 mg/cc, pain was reduced after 1 day and signs of inflammation after 7 days.
Another study found improved response when the total dose was above 4 milligrams triamcinolone per lesion, suggesting that the total lesional dose may be more important than the concentration of the triamcinolone injected.
I & D is recommended only for acute HS abscesses to relieve pain where injection or other interventions are not possible.
Sinuses and fistulas do not usually respond to medical therapy and require a surgical approach, usually deroofing. Deroofing is highly effective and relatively easy to perform in a doctor's office.
Eventually, if medical therapy is not successful and the patient desires a "cure," a surgical approach may be considered This usually consists of excision of all diseased tissue in the area. Limited excisions usually result in recurrence adjacent to the scar.
The initial bump of HS.
The bump may slowly resolve, or open up and drain as shown here.
Multiple lesions with inflammation, drainage and scarring.
Once the inflammation has resolved, significant scarring may remain.
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