Hidradenitis suppurativa

February 2, 2017

Hidradenitis suppurativa or HS is a skin disease that affects areas bearing apocrine sweat glands and hair follicles; such as the underarms, groin and buttocks, and under the breasts in women.

Also known as acne inversa, HS is a chronic inflammatory disease of the terminal follicular epithelium, often occurring in areas rich in apocrine glands. Originally thought to arise from these glands, the condition is now believed to begin through follicular abnormalities.

It may be associated with other follicular-dysfunction processes such as acne, boils in the scalp (folliculitis decalvans) or pilonidal cyst. The process arises in the mid-to-deep dermis and does not seem to be caused by bacterial agents.

It is typically characterized by erythematous, tender, sterile nodules of various sizes that develop insidiously in the inguinal, perianal, submammary, and axillary regions. These nodules may progress to frank abscesses that not only drain to produce a very foul odor but also further develop tunneling, cavitations and sinus tracts in the affected areas, leading to the development of scars and keloids. Rarely, contractures and immobility may result.

This painful condition can cause social isolation and depression . Depending on the severity of symptoms, HS will often significantly impact the quality of life of patients, begging the need for more effective treatment regimens and therapeutic options.


No one knows for sure what causes HS. Because it occurs after puberty, hormones likely play a role. The person’s immune system also seems to play a role.

It is possible that HS develops when the person’s immune system overreacts. HS begins in the hair follicles (where hair grows out of the skin). Like everyday acne, HS forms when the hair follicles clog with bacteria and other substances. It is possible that HS develops in people who have an immune system that overreacts to the plugged hair follicle.

Hormones are involved in the control of apocrine sweat glands and certainly play a part in the disease. Hidradenitis suppurativa affects women more often than men. It does not start before puberty or after the menopause. It may get better during pregnancy, but is often worse before menstrual periods. Some patients do well with hormone treatments.

Bacteria play a part too, but a variety of germs, and not just one special type, is found in the spots. It is not clear whether they cause the disease, or just flourish within it.

There may be a link with acne.

Lifestyle also seems to play a role. It seems that smoking, being overweight, or taking lithium may trigger HS. These things do not cause HS. If a person is susceptible to getting HS, any of these could make HS appear for the first time or worsen existing HS.

Although the exact cause is still unknown, dermatologists have learned the following from studying HS –

  • It is not contagious.
  • Poor hygiene does not cause HS.
  • About one-third of people who get HS have a blood relative who has HS

Risk Factors

Hidradenitis affects 2-3% of the US population, but the number may be higher because so few people discuss this painful condition with their doctors. Other factors associated with developing hidradenitis, include being –

  • Female: Hidradenitis affects four times more women than men
  • African American
  • Obese
  • A smoker

Hormonal influences are also thought to influence who will develop the condition, but there is no clear evidence that this is the case.


Hidradenitis suppurativa commonly occurs around hair follicles, where many oil and sweat glands are found, such as in the armpits, groin and anal area. It may also occur in areas where skin rubs together, such as the inner thighs, under the breasts or between the buttocks. Hidradenitis suppurativa can affect a single area or multiple areas of the body.

Signs and symptoms of hidradenitis suppurativa include –

Blackheads – Small pitted areas of skin containing blackheads — often appearing in pairs or a “double-barreled” pattern — are a common feature.

Red, tender bumps – These bumps, or lesions, often enlarge, break open and drain pus. The drainage may have an unpleasant odor. Itching, burning and excessive sweating may accompany the bumps.

Painful, pea-sized lumps – These hard lumps, which develop under the skin, may persist for years, enlarge and become inflamed.

Leaking bumps or sores – These open wounds heal very slowly, if at all, often leading to scarring and the development of tunnels under the skin.

Hidradenitis suppurativa often starts after puberty with a single, painful bump that persists for weeks or months. For some people, the disease progressively worsens and affects multiple areas of their body. Other people experience only mild symptoms. Excess weight, stress, hormonal changes, heat or excessive perspiration can worsen symptoms.


Hidradenitis suppurativa often causes complications when the disease is persistent and severe. These complications include –

Scars and skin changes – Severe hidradenitis suppurativa may leave rope-like scars, pitted skin or patches of skin that are darker than normal.

Restricted movement – Open sores and scar tissue may cause limited or painful movement, especially when the disease affects the armpits or thighs.

Obstructed lymph drainage – The most common sites for hidradenitis suppurativa also contain many lymph nodes. Scar tissue can interfere with the lymph drainage system, which may result in swelling in the arms, legs or genitals.

Social isolation – The location, drainage and odor of the sores — singly or in combination — can cause embarrassment and reluctance to go out in public, leading to depression.



  • Topical clindamycin, with benzoyl peroxide to reduce bacterial resistance
  • Short course of oral antibiotics for acute staphylococcal abscesses, eg flucloxacillin
  • Prolonged courses (minimum 3 months) of tetracycline, metronidazole, cotrimoxazole, fluoroquinolones or dapsone for their anti-inflammatory action
  • Six-to-twelve week courses of the combination of clindamycin (or doxycycline) and rifampicin for severe disease



Antiandrogens – Long-term oral contraceptive pill; antiandrogenic progesterones drospirenone or cyproterone acetate may be more effective than standard combined pills. These are more suitable than progesterone-only pills or devices.

Immunomodulatory treatments for severe diseases –

  • Intralesional corticosteroids into nodules
  • Systemic corticosteroids short-term for flares
  • Methotrexate, ciclosporin, and azathioprine
  • TNFα inhibitors adalimumab and infliximab, used in higher dose than required for psoriasis, are the most successful treatments to date

Other medical treatments –

  • Metformin in patients with insulin resistance
  • Acitretin (unsuitable for females of childbearing potential)
  • Isotretinoin – more effective for acne
  • Colchicine

Surgeries –

  • Incision and drainage of acute abscesses
  • Curettage and deroofing of nodules, abscesses and sinuses
  • Laser ablation of nodules, abscesses and sinuses
  • Wide local excision of persistent nodules
  • Radical excisional surgery of entire affected areaa
  • Laser hair removal

Self Help –

  • Weight loss; follow low-glycaemic, low-dairy diet
  • Smoking cessation: this can lead to improvement within a few months
  • Loose fitting clothing
  • Daily unfragranced antiperspirants
  • If prone to secondary infection, wash with antiseptics or take bleach baths
  • Apply hydrogen peroxide solution or medical grade honey to reduce malodour
  • Apply simple dressings to draining sinuses
  • Analgesics, such as paracetamol (acetaminophen), for pain control.

Alternative Treatment

Zinc – One nutrient that may be helpful in this condition is zinc. Zinc may help lower androgen levels that can lead to excess oil production and gland blockage, and have anti-inflammatory properties.

Anti-inflammatory Therapies – From a naturopathic approach, HS may be addressed using nutrients, herbs and dietary strategies that offer anti-inflammatory properties. Lowering any inflammatory triggers and possible contributing compounds like cytokines in the body may improve redness and aggravation of lesions. Identifying food triggers may be a start – in the patients I have seen with this condition decreasing intake of dairy and refined sugar seemed to provide some relief, although triggers are likely patient specific. An IgG food sensitivity test may help guide dietary elimination if triggers are unclear.

Weight Management – There is a high correlation in presence of HS and obesity, and studies suggest that degree of obesity corresponds with severity of disease. In patients who are overweight or obese, body mass may be contributing in several ways this condition. Excess adipose tissue has been shown to increase levels of inflammation and affect hormone levels, which may aggravate the inflammatory lesions involved in HS. Increased body weight may also aggravate friction in folds and predispose to obstruction and irritation of lesions that are present, while another possible explanation for this connection is a common underlying genetic predisposition to obesity and HS that is currently being investigated. (7) Weight loss as a treatment for HS has been investigated in one small study demonstrating a 15% weight loss is associated with significant disease improvement (8). HS is however not uncommon in patients of normal body weight, in whom weight loss would not be likely to influence disease progression, and in some patients weight loss an leave skin folds that increase friction. This observation also suggests that weight could be more of an aggravating factor that a cause of this condition.

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