Hidradenitis suppurativa (HS), also known as Acne Inversa, is a chronic disease consisting of blackheads, painful cysts and abscesses that form in body fold areas, like underarms and groin, where there are hair follicles and apocrine sweat glands. It may affect one or multiple areas of the body.
The abscesses usually develop into difficult-to-heal open wounds and scarring.
Due to recurrent, draining, pus-filled boils and abscesses, hidradenitis is a physically, socially and psychologically disabling disease.
Who gets hidradenitis suppurativa?
HS affects approximately 1-4% of the population of the world. It affects women 3 times more often than men, and tends to run in families. Hidradenitis suppurativa tends to start after puberty, persist for years and worsen over time. It tends to decrease in severity or disappear after menopause. There are no ethnic differences in who gets hidradenitis suppurativa.
Almost 70% of patients with hidradenitis have mild disease. However, the quality of life is significantly worsened even in mild cases, especially in how patients view themselves.
The two strongest risk factors for developing hidradenitis suppurativa are smoking and overweight.
Although believed to be risk factors previously, antiperspirants, deodorants, powders and shaving are not considered risk factors for HS.
It has been reported that Karl Marx, the founder of communism, suffered from this disease.
What are the characteristics of hidradenitis suppurativa?
The extent and severity of hidradenitis varies tremendously between individuals. According to the criteria of the international symposium of the Hidradenitis Suppurativa Foundation of March 2009, to make a diagnosis of hidradenitis suppurativa, the following must be present:
Blackheads, deep-seated painful nodules and boils early on, then abscesses, draining sinuses and bridged scars in later stages of disease
Location in the underarms, groin, perianal region, buttocks, skin under and between breasts. The neck and area behind the ears can also be affected. Pilonidal sinuses are quite common.
Chronic and recurrent
Flares of hidradenitis are about 7-15 days in duration. Lesions can resolve on their own or form non-closing wounds, sinuses and scars.
The most commonly affected sites are:
Groin, including inner thigh
Scrotum or vulva
Perianal and perineal regions
Between and under breasts
What does hidradenitis look like?
Abscesses, chronically draining nodules and sinuses, blackheads and scarring are all seen in hidradenitis.
Photos courtesy of Global Skin Atlas and Dermquest.com
What causes hidradenitis suppurativa?
It is not known what causes hidradenitis. Some contributing factors include:
In some studies, 70-89% of patients with hidradenitis suppurativa are or have been smokers.
Clinically, it is extremely difficult to control this disease if patients continue smoking.
30-40% of patients with hidradenitis have a family history of the disease.
Patients with a family history tend to have milder disease with earlier onset.
Bacterial infections contribute to the manifestations of hidradenitis but do not cause it.
Women are affected 3 times more often than men.
Many women suffer premenstrual flares of hidradenitis.
Hidradenitis gets better during pregnancy.
Hidradenitis is occasionally associated with polycystic ovary syndrome and insulin resistance.
Tests for hormone levels and insulin resistance need to be done in all women who develop hidradenitis.
Hidradenitis improves after menopause.
Certain medications can trigger or flare hidradenitis
Hidradenitis can be found in overweight and non-overweight patients, but hormones and friction in overweight patients can make the disease significantly worse.
What other conditions are associated with hidradenitis?
There are a number of diseases associated with hidradenitis suppurativa. Some of them are listed below.
Other diseases with blockage of hair follicles (follicular occlusive tetrad)
Acne (acne vulgaris)
Severe acne (acne conglobata)
Dissecting cellulitis of the scalp
Treatments for hidradenitis suppurativa
There is no single effective treatment or cure of hidradenitis. The only permanent cure is surgical removal or all affected areas of the skin.
Most patients require a combination of medical and surgical treatments.
Gentle washing with a nonsoap cleansing bar, avoiding friction or irritation. Washcloths or spongies should not be used.
Staying out of heat and humidity.
Stopping smoking and avoiding nicotine-replacement products.
Surgery of hidradenitis includes openining and draining the abscesses as necessary and/or excision of entire involved areas in severe cases.
Intralesional injections of steroid medication to decrease inflammation.
Topical and oral antibiotics, depending on the severity of disease
Immunosuppressive medications, like TNF alpha inhibitors, cyclosporine or corticosteroids.
Isotretinoin (Accutane) is helpful in 25% of patients with hidradenitis.
Laser treatments are now being investigated for hidradenitis suppurativa,
Excellent articles on hidradenitis suppurativa:
Hidradenitis suppurativa in 64 female patients: retrospective study comparing oral antibiotics and antiandrogen therapy. Kraft JN, Searles GE. J Cutan Med Surg 2007; 11(4): 125-31
Cigarette smoking as a triggering factor of hidradenitis suppurativa. Konig A, Lehmann C, Rompel R, Happle R. Dermatology 1999; 198(3): 261-4
Hidradenitis suppurativa. Revuz J. La Presse Medicale 2010; 39(2): 1254-1264
Histopathologic study of hidradenitis suppurativa following long-pulsed 1064-nm Nd:YAG Laser Treatment. Xu LY et al. Arch Dermatol 2010; pulished online E1-E8.
Hidradenitis suppurativa: A comprehensive review. Alikhan A, Lynch PJ, Eisen DB. JAAD 2009; 60: 539-61
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