Hidradenitis Suppurativa (HS) Diagnosis and Treatment

Hidradenitis suppurativa (HS) is a chronic, non-contagious, inflammatory skin condition that causes painful, recurring boils in areas with sweat glands. In severe cases, these boils can break open, resulting in pus draining weeping boils or making tunnels under your skin. HS is most likely to develop where your skin rubs together, such as underarms, groin, or between the buttocks. Currently, there is no cure for this condition, but many good treatments are available to manage symptoms. HS often appears around puberty, and it is more common in women and individuals of African descent. Another name for HS is acne inversa and it is reasonable to think of this condition as a form of scarring acne of the body folds.

The main symptom of HS is the development of lumps under the skin that can be painful and tend to enlarge and drain pus. HS symptoms may come and go. HS symptoms can vary in severity, and depending on the severity, HS can be graded from stage I (mild) to III (severe). Some common symptoms of HS are:

• Painful, red bumps or nodules: HS often starts with small, painful, and inflamed bumps or nodules that may appear in areas where skin rubs together, such as the armpits, groins, buttocks, and under the breasts. These bumps can be tender to the touch.
• Abscesses: The nodules can progress to larger, painful abscesses filled with pus. These can rupture, draining foul smelling pus.
• Tunnels and tracts: Over time, tunnels or tracts may form under the skin, connecting the affected areas. These can be deep and often painful.
• Scarring: As the condition persists, it can lead to the formation of scars, which can be extensive and disfiguring in severe cases.
• Recurring flare-ups: HS is characterized by recurrent flare-ups and remissions. Symptoms may worsen during times of stress, hormonal changes, or when the affected areas become irritated.
• Pain and discomfort: HS can be quite painful, making it uncomfortable to move or perform daily activities, especially when abscesses or nodules are present.
• Draining pus and odor: The drainage of pus from the abscesses can have a foul odor, which can be distressing for individuals with HS.
• Skin thickening: In some cases, the skin in the affected areas may become thicker and develop a cobblestone like appearance.

Pathogenesis of HS is not clear. However, HS is considered as an autoinflammatory disease of the hair follicles and oil glands and sweat glands. This means that inflammation gathers around your hair follicles leading to the development of HS. The severity of the condition can vary, with some individuals experiencing mild symptoms and others having more severe and extensive lesions.

HS primarily affects areas of the body where there are sweat glands and hair follicles. The most commonly affected areas include

• Armpits
• Groin
• Buttocks
• Under the breasts
• Perianal area (area around the anus)
• Between the fingers and toes.

It is worth noting that HS is a condition that varies from person to person, and it can potentially develop in other regions where sweat glands and hair follicles are present.

No, HS is not contagious. As HS is an autoinflammatory disease not a disease caused by an infection (virus or bacteria) it will not pass from one person to another.

Currently, there is no cure for HS. However, there are various treatment options available that can help to manage and control the symptoms, reduce flare-ups, and improve the quality of life.

While it may not be entirely preventable in all cases, there are steps you can take to reduce the risk of developing HS or manage the conditions if you already have it. Some common preventive measures include:

• Weight management: Obesity is a risk factor for HS. Maintaining a healthy weight can help reduce the risk of developing HS and may also improve symptoms in individuals who already have conditions.
• Quit smoking if you are a tobacco user: Smoking is associated with a higher risk of developing HS and can worsen the condition in those who already have it. Therefore quitting smoking can be a crucial step in managing HS.
• Avoid tight clothing: Wear loose-fitting clothing made from breathable fabrics to reduce friction and irritation in areas prone to HS lesions.
• Manage sweating: Excessive sweating can exacerbate HS. You can try strategies such as staying indoors when it is hot outside. However, as the use of antiperspirants/deodorants seems to worsen HS in some individuals 2, it is better to use caution when managing sweating with those products.
• Avoid shaving affected areas: Shaving can irritate the skin and potentially worsen HS. If possible, it is better to avoid shaving in areas prone to HS lesions.
• Manage stress: High levels of stress can trigger or exacerbate HS symptoms. Stress management techniques, such as meditation and deep breathing exercises might help with HS symptoms.

Treatment options may include antibiotics, topical treatments, lifestyle modifications, and in severe cases, surgical interventions or biological medications. A dermatologist is the healthcare provider typically best equipped to diagnose and manage HS. Some of the common treatment options include following:

• Topical medication: Two types of topical medications are used to control HS symptoms
  • Topical antibiotics: Antibiotic creams or ointments can help reduce inflammation and control infection in mild cases.
  • Topical steroids: Steroid creams may be used to reduce inflammation and discomfort in affected areas.
• Oral medications: Several oral medications can be used to control HS symptoms
  • Oral antibiotics: To control bacterial growth and inflammation, oral antibiotics such as tetracycline, clindamycin, or doxycycline are prescribed.
  • Anti-inflammatory medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids may be used to reduce pain and inflammation during flare-ups of HS. Some patients respond to the anti-inflammatory effects of isotretinoin, also known as Accutane.
  • Hormonal therapies: In some cases, hormonal therapies like oral contraceptives or anti-androgens may be considered, especially in women with hormonal imbalances that contribute to HS.
• Biologics: For moderate to severe cases of HS, biologics can be prescribed. Biologics are a class of medications that are derived from living organisms or their components such as antibodies. Adalimumab (Humira) and infliximab (Remicade) are biologics used to reduce inflammation in HS patients. These drugs are administered by injection or infusion.
• Lifestyle modifications: Weight management, smoking cessation, and dietary changes can be some of the lifestyle modifications that can be used to treat HS symptoms. Proper wound care and hygiene are important to prevent infection and promote healing of abscesses and lesions associated with HS.
• Surgical interventions: For large, painful abscesses, healthcare providers may make an incision and drain the pus to relieve the pressure. In severe cases, surgical removal of the affected tissues can be done to reduce the recurrence of lesions.
• Intralesional steroid injections: A dermatologist may directly inject corticosteroids into HS lesions to reduce inflammation and pain.3
• Immunosuppressive medications: In some cases, immunosuppressive medications like cyclosporine and methotrexate may be prescribed to control inflammation.
• New medicines: there are new treatments under development to treat HS. Ask one of the board-certified dermatologists at Saguaro Dermatology if you may be a candidate for a clinical trial.

Some natural remedies may help with the HS symptoms. As there is limited scientific evidence for the safety and efficacy of these home remedies, consider talking to a doctor before taking supplements or using essential oil or other home remedies.

• Tea tree oil: Some people with HS have reported relief from applying diluted tea tree oil to affected areas. Be cautious when using essential oils, as they can irritate your skin. Always dilute them and perform a patch test first.
• Zinc: Low blood zinc levels were more common in individuals with HS compared to healthy individuals and correlated to the severity of the disease 6 . While more research needs to be done to explore whether or not zinc supplements are beneficial for treating HS, zinc supplements may help with HS symptoms.
• Neem oil: As neem oil can reduce redness and inflammation, it may also help heal HS scars. When using on the skin, it should be mixed with a carrier oil or aloe vera.
• Apple cider vinegar: As apple cider vinegar can prevent bacterial infection, it can be used on HS lesions.

HS can significantly impact a person’s quality of life due to pain, discomfort, and potential scarring it causes. If you suspect you have HS or are experiencing symptoms, it is important to seek medical attention. Early interventions and proper management can help reduce symptoms and improve the condition’s long-term outlook. The team at Saguaro Dermatology has successfully treated individuals with a multitude of skin conditions, including HS. Our board-certified dermatologists along with our caring and experienced staff are always ready to help you at Saguaro Dermatology, conveniently located at three campuses in Ahwatukee, Central Phoenix and Mesa.