Hidradenitis suppurativa

Overview

Hidradenitis suppurativa (hi-drad-uh-NIE-tis sup-yoo-ruh-TIE-vuh), also known as acne inversa, is a condition that causes small, painful lumps to form under the skin. The lumps usually develop in areas where your skin rubs together, such as the armpits, groin, buttocks and breasts. The lumps heal slowly, recur, and can lead to tunnels under the skin and scarring.

Hidradenitis suppurativa tends to start after puberty, usually before age 40. It can persist for many years and worsen over time. It can affect your daily life and emotional well-being. Combined medical and surgical therapy can help manage the disease and prevent complications.

Women are three times more likely to develop hidradenitis suppurativa, though this ratio can differ by location around the world. Also, Black people are more likely to develop this disease than people of other races. This could be attributed to genetic factors.

Symptoms

Hidradenitis suppurativa can affect one or several areas of the body. Signs and symptoms of the condition include:

• Blackheads. Blackheads appear in small, pitted areas of skin, often appearing in pairs.
• Painful pea-sized lumps. The condition usually starts with a single, painful lump under the skin that persists for weeks or months. More bumps may form later, usually in areas where you have more sweat and oil glands or where the skin rubs together, such as the armpits, groin, buttocks and breasts.
• Leaking bumps or sores. Some bumps or sores get bigger, break open and drain pus with an odor.
• Tunnels. Over time, tunnels might form under the skin, connecting the lumps. These wounds heal slowly, if at all, and drain blood and pus.

Some people with this condition experience only mild symptoms. The course of the disease is highly variable. Excess weight and being a smoker are associated with worse symptoms, but people who are thin and don't smoke can experience severe disease.

When to see a doctor

Early diagnosis of hidradenitis suppurativa is key to effective treatment. See your dermatologist if your condition:

• Is painful.
• Makes it difficult to move.
• Doesn't improve in a few weeks.
• Returns within weeks of treatment.
• Appears in several locations.
• Flares often.

Your dermatologist can create a treatment plan for you.

Hidradenitis suppurativa is not just a boil, and many people with this condition also have related conditions. People with hidradenitis suppurativa benefit from a health care team with medical and surgical dermatologists at the core. Other specialists are involved as needed.

Causes

Hidradenitis suppurativa develops when hair follicles become blocked, but why this blockage occurs isn't known. Experts think it could be connected to hormones, genetic predisposition, cigarette smoking or excess weight.

An infection or being unclean does not cause hidradenitis suppurativa, and it can't be spread to other people.

Risk factors

Factors that increase your chance of developing hidradenitis suppurativa include:

• Age. The risk of hidradenitis suppurativa is higher for people in their teens and 20s.
• Sex. Females are more likely to develop hidradenitis suppurativa than males.
• Race. Ethnicity or race might affect risk level. The condition occurs most in Black people, possibly due to genetic factors.
• Family history. A tendency to develop hidradenitis suppurativa can be inherited.
• Certain conditions. Hidradenitis suppurativa is more common and severe in people who are overweight. It also has an association with severe acne, arthritis, diabetes, metabolic syndrome and inflammatory bowel disease.
• Smoking. Smoking tobacco has been linked to hidradenitis suppurativa.

Complications

Persistent and severe hidradenitis suppurativa can cause complications, including:

• Infection. Secondary infection is possible in the affected area, but the presence of pus is common in hidradenitis suppurativa and doesn't necessarily mean infection.
• Scars and skin changes. The wounds may heal but leave ropelike scars or pitted skin.
• Restricted movement. Sores and scar tissue can cause limited or painful movement, especially when the disease affects the armpits or thighs.
• Skin cancer. Squamous cell carcinoma has been reported with long-term hidradenitis suppurativa, particularly in people whose condition involves the perianal area. This area consists of the tissues around the anus.
• Swelling in the arms, legs or genitals. The most common sites for hidradenitis suppurativa also contain many lymph nodes. Scar tissue can interfere with the lymph drainage system, which can cause the arms, legs or genitals to swell.
• Psychological effects and social isolation. The location, drainage and odor of the sores can cause embarrassment and reluctance to go out in public, leading to anxiety or depression.
• Lifelong pain. This pain is much worse than diseases such as psoriasis.

Diagnosis

Hidradenitis suppurativa can be mistaken for pimples or acne. For many people, it takes years to receive a correct diagnosis.

Your health care provider will base a diagnosis on your signs and symptoms, skin appearance, and medical history. You might be referred to a health care provider who specializes in skin conditions, also known as a dermatologist. Hidradenitis suppurativa can be difficult to diagnose and requires specialized care.

No laboratory test is available to diagnose hidradenitis suppurativa. But if pus or drainage is present, your health care provider might take a sample for lab testing.

Treatment

Treatment with medicines, surgery or both can help control symptoms and prevent complications of hidradenitis suppurativa. Talk with your health care provider about the risks and benefits of the treatment options and how to develop an approach that's right for you.

Expect to have regular follow-up visits with your dermatologist. Some people might need the comprehensive care provided by a health care team with members from multiple medical specialties.

Medications

Your health care provider might prescribe one or more of these types of medicines:

• Antibiotics. An antibiotic applied to the skin in liquid or gel form may be used to manage mild symptoms. These types of medicines are called topical antibiotics. For more widespread disease, your health care provider might prescribe antibiotic pills, such as doxycycline, or Monodox; clindamycin, or Cleocin; rifampin, or Rimactane; or more than one of these medicines. Rifampin also is known as rifampicin. People with severe disease might need to take antibiotics for months.
• Steroid injections. Triamcinolone acetonide, or Kenalog-10, injected into the sores might reduce swelling and inflammation.
• Hormonal therapy. Hormone pills, such as estrogen-containing combined oral contraceptives such as estradiol and estradiol/norgestimate might be effective for people with mild hidradenitis suppurativa. Spironolactone often is used to reduce the need for antibiotics, and isotretinoin, which is a medicine that is used mostly to treat acne. Isotretinoin is sometimes used to treat hidradenitis suppurativa.
• Biologics. These medicines, usually administered by injection, alter the immune system in a way that disrupts the disease cycle and improves symptoms and signs of disease within weeks. Several of these medicines are approved to treat moderate to severe hidradenitis suppurativa. Two are the tumor necrosis factor inhibitors adalimumab, or Humira, and infliximab, or Remicade. These medicines work by dampening part of the immune system called tumor necrosis factor. Many other biologics are in clinical trials for hidradenitis suppurativa.
• Retinoids. Oral retinoids might be an option for some people with acne-like disease. These medicines are not recommended when you're pregnant, breastfeeding or if you intend to become pregnant.
• Pain medicine. If pain relievers available without a prescription don't help, your health care provider might prescribe a stronger pain medicine or refer you to a pain clinic.

Surgery or other procedures

Combined medical and surgical approaches help manage hidradenitis suppurativa. Surgery is an important part of disease management when a tunnel, and bump, or abscess, are present. Which surgical approach is right for you depends on the extent and severity of your condition. Talk with your health care provider about the risks and benefits of the options, including:

• Uncovering the tunnels. This procedure involves removing tissue to expose the tunnels under the skin. This also is known as unroofing. It's used for people with moderate or severe hidradenitis suppurativa. This solution usually doesn't have to be repeated.
• Punch debridement. This procedure, also called limited unroofing, involves removing a single inflamed bump.
• Laser therapy. A carbon dioxide laser can be used to make hidradenitis suppurativa sores go away. After this treatment, the sores are unlikely to return. Laser hair removal can help hidradenitis suppurativa in its early stages.
• Surgical removal. This approach might be an option for people with persistent or severe symptoms. It involves removing all the affected skin. A skin graft might be needed to close the wound. Even after surgery, sores might still occur in other areas.
• Incision and drainage. Surgical drainage is no longer considered an effective option for treating hidradenitis suppurativa. The method might be considered to provide short-term pain relief, but sores usually flare again afterward.

Lifestyle and home remedies

Mild hidradenitis suppurativa can sometimes be effectively controlled with self-care measures. Self-care is also an important complement to medical treatment.

These suggestions might relieve discomfort, speed healing or prevent flare-ups:

• Follow a daily skin care routine. Gently wash your body with a cleanser that is not soap. It can sometimes be helpful to use an antiseptic wash such as chlorhexidine 4% or benzoyl peroxide wash when showering. Try it once a week at first and then increase use to once daily if your skin tolerates it well. Pat dry. When washing, avoid using washcloths, loofahs or other such items on affected areas, as they can irritate skin. Don't squeeze pimples and sores. And avoid shaving or using hair-removing, or depilatory, creams.
• Manage your pain. Gently applying a warm compress can reduce swelling and ease pain. Ask your health care provider about an appropriate pain reliever and how to care for your wounds at home.
• Try to keep or achieve a healthy weight and stay active. Not being at a healthy weight can worsen the symptoms of hidradenitis suppurativa. Talk with your health care team to develop a plan. Try to find activities that don't irritate your skin.
• Consider altering your diet. Diets that include dairy, red meat and foods with a high glycemic index might worsen hidradenitis suppurativa symptoms. If your diet includes these foods, talk with a dietitian about the benefits of eliminating them.
• Quit smoking. If you smoke, try to quit. Stopping smoking can ease the symptoms of hidradenitis suppurativa.

Coping and support

Hidradenitis suppurativa can be a challenge to your emotional health and well-being. Painful sores might affect your sleep, ability to move or sex life. Or the sores might drain pus with an odor, which might make you feel anxious, embarrassed, angry, self-conscious or depressed. The ongoing, persistent nature of the disease and its treatment challenges add to the burden.

Try to find support among your family and friends. The concern and understanding of other people with hidradenitis suppurativa also might be comforting. Ask for help with your mental health and coping strategies. Your health care provider can refer you to a mental health professional or provide the contact information for a support group.

Preparing for an appointment

You'll likely first see your primary care provider. You might then be referred to a health care provider who specializes in diagnosing and treating skin diseases, also known as a dermatologist. Depending on the severity of your condition, your care also might involve specialists in colorectal surgery, plastic surgery or gastroenterology.

Here's some information to help you get ready for your appointment.

What you can do

Make a list of:

• The symptoms you're experiencing, including any that may seem unrelated to the reason you scheduled the appointment.
• All medicines, vitamins and supplements you take, including their doses.

Also, note the questions to ask your health care provider, including:

• What's the most likely cause of my symptoms?
• Are there other possible causes?
• Do I need any tests?
• How long will my condition last?
• What treatments are available, and which do you recommend for me?
• What side effects can I expect from treatment?
• Is this condition related to another medical disorder?
• Do you have any brochures or other printed materials that I can take with me? What websites do you recommend?

What to expect from your doctor

Your health care provider is likely to ask you several questions, such as:

• When did your symptoms begin?
• What did the skin lumps look like when they started?
• Do they come back in the same spots?
• Are your symptoms painful?
• Have your parents or siblings ever had this problem?
• What, if anything, seems to improve your symptoms?
• What, if anything, seems to worsen your symptoms?
• Do you smoke or use tobacco products?