Hidradenitis Suppurativa


Article Author:
Kimberly Ballard


Article Editor:
Victoria Shuman


Editors In Chief:
Stephen Leslie
Karim Hamawy


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
2/28/2019 8:39:55 AM

Introduction

Hidradenitis suppurativa (HS), also called acne inversus, is a chronic inflammatory skin condition with lesions including deep-seated nodules and abscesses, draining tracts, and fibrotic scars. These lesions most commonly occur in intertriginous areas and areas rich in apocrine glands. Among the most common are axillary, groin, perianal, perineal, and inframammary locations. Treatment varies based on severity and can include topical and systemic antibiotics, hormone therapy, immune modulators, and surgery. Because of the associated pain, sensitive locations, drainage, odor and scarring, this condition may have a negative psychosocial impact.

Etiology

The etiology of HS appears to have genetic, environmental, and behavioral influences.[1]

Thirty-three to 40% of individuals with HS report an affected first-degree relative, suggesting a hereditary component with an autosomal dominant transmission pattern. In a small subset of affected families, researchers have identified a mutation of the gamma-secretase Notch signaling pathway.

Environmental and behavioral factors also contribute. Individuals with HS are more commonly overweight or obese. Obesity leads to greater intertriginous surface area and skin friction, increased sweat production and retention, and hormonal changes leading to relative androgen excess, all of which are associated with HS.  Metabolic syndrome is more common in obese individuals and thus is also seen more commonly in HS.

Smoking is also prevalent among those diagnosed with HS. Causation is unclear; however, nicotine may cause increased follicular plugging. As with obesity; disease progression and severity are worse in those who smoke.

The influence of hormones can be seen in HS.   There is a greater prevalance in females than males, with the age of primary occurance most commonly between puberty and menopause.  In addition, there are  fluctuations of occurance and severity with menstrual cycles and exogenous hormones.

Epidemiology

Estimated prevalence ranges from under 1% to 4%. These numbers are likely underestimated because of under-reporting and misdiagnosis. The onset of the condition is commonly between puberty and age 40, most frequently from age 21 to 29. Women are more commonly affected than men in an approximate ratio of 3 to 1. There is a lack of evidence to show a pattern of racial or ethnic predilection.[2]

Pathophysiology

The pathologic process of HS begins when a defective hair follicle becomes occluded and ruptures, spilling its contents, including keratin and bacteria, into the surrounding dermis. A chemotactic inflammatory response by surrounding neutrophils and lymphocytes can then lead to abscess formation and subsequent destruction of the pilosebaceous unit and other adjacent structures. Other possible contributors to pathology include abnormal antimicrobial peptides, abnormal secretion of apocrine glands, abnormal invaginations of the epidermis leading to tract formation, and deficient numbers of sebaceous glands.[3][4]

Immunological abnormalities have also been observed.  Elevated levels of inflammatory cytokines including tumor necrosis factor alpha and various interleukins have been detected in the lesions of HS and provide possible targets for emerging treatments. Bacteria do not appear to be causative. Aspirate from an unruptured lesion typically yields a sterile culture. However, bacterial infection and colonization that occur during the process can secondarily worsen HS.[1]

History and Physical

Because the early stages of HS are often mistaken for other conditions, the average delay in the correct diagnosis is 7 years.[1] Clinical diagnosis requires recognition of the morphology (deep, inflamed, painful nodules, sinus tracts, scars), the location (intertriginous areas, apocrine gland containing areas), and the chronicity of the disease process (prolonged course with periods of activity and remission).

Up to half of the individuals will report a prodromal syndrome involving burning, stinging, pain, pruritus, warmth, or hyperhidrosis in the area 12 to 48 hours before the appearance of a lesion. Triggers can include menstruation, weight gain, stress, hormonal changes, excessive heat, and perspiration. On presentation, individuals are typically well appearing and afebrile, unless secondary infection or advanced disease is present.

Characteristic primary lesions are deep-seated nodules, usually 0.5 to 2 cm that last from days to months. They are often mistaken for furuncles or “boils.” However, while a furuncle will respond rapidly to drainage or antibiotics, the nodules of HS are deep and can rupture and track subcutaneously. Multiple recurrent nodules in the same area may lead to the formation of intercommunicating sinus tracts that can ulcerate or drain. Drainage may be purulent and malodorous. Other lesions include open comedones (described as a “tombstone” comedones), often double or multi-headed. In advanced stages, thick fibrotic scars and plaques can develop leading to architectural distortion of the area.

The axilla is the most common location for HS lesions. Other common areas are inguinal, inner thighs, perianal and perineal, inframammary, buttocks, pubic area, scrotum, vulva, trunk, and less commonly the scalp and retro-auricular areas.

Pertinent history includes onset from puberty into young adulthood and a history of recurrent lesions with intermittent improvement or resolution. HS is a chronic condition. Identifying a family history of a similar condition is also helpful in establishing the proper diagnosis.

Once the history and complete physical exam is complete, the  Hurley staging system can be used to classify the case.

  • Hurley Stage I: Abscess formation without tracts or scars
  • Hurley Stage II: Recurrent abscesses with sinus tracts and scarring; there may single or widely separated lesions
  • Hurley Stage III: Diffuse involvement, multiple interconnected sinus tracts, and abscesses across an entire area leaving little to no uninvolved skin

HS is one component of the follicular occlusion tetrad which also includes acne conglobata, dissecting cellulitis of the scalp, and pilonidal sinus. Diagnosis of HS in an individual warrants evaluation for these coexisting diagnoses.  Physicians should also keep in mind the association of metabolic syndrome, inflammatory bowel disease, and spondyloarthropathy and assess for these conditions during the history and physical.

Evaluation

There are no biological or pathological tests of diagnosis. Diagnosis does not require a biopsy. However, a biopsy is beneficial to rule out squamous cell carcinoma in the presence of severe HS if the diagnosis is uncertain. Bacterial cultures are not beneficial unless secondary infection or an alternative diagnosis is suspected. Imaging is not typically helpful; however, ultrasound may be a useful tool pre-operatively to identify the extent of sinus tracts. Lesions may warrant further imaging including MRI in severe perianal disease.

Treatment / Management

Overall goals include treating existing lesions to minimize pain and drainage, decreasing the frequency of recurrence, and prevention of disease progression.

Since limited studies exist comparing treatment regimens, most treatment algorithms are based on expert opinion and consensus.

In early uncomplicated disease, topical antibiotics are the first line treatment. Topical clindamycin has been the most effective. [5] Intralesional corticosteroids can reduce local inflammation, and partial de-roofing (punch debridement) of individual lesions can facilitate healing.

Treatment for Hurley Stage II and resistant Hurley Stage I involves oral antibiotics.  Antibiotics in the tetracycline family have been the most effective. [6] If treatment failure persists, combination therapy with oral clindamycin plus rifampin is recommended. [7] Anti-androgenic hormonal therapy which includes Cyproterone acetate, oral contraceptives, spironolactone, and finasteride can also be helpful.[8] Oral retinoids have shown mixed responsiveness. While isotretinoin is most effective in acne, acitretin appears to be more effective in HS. [9][10] Systemic steroids are effective for some individuals.

For Hurley stage III and resistant lower stages, tumor necrosis factor-alpha inhibitors are indicated. Adalimumab is the only FDA-approved medication to treat HS.[11]

Surgery is often needed at this stage, and involves a wide excision to include the lesions, tracts, and scars of an entire affected area. A combination of medical treatment and surgical excision is often the preferred approach. Other therapeutic options may include localized laser and pulsed light therapy which help to disrupt the inflammatory process.[12]

Pain management is also critical. The pain of HS is both inflammatory and non-inflammatory. Sources of pain can include scarring (causing tensile pain), keloids, abscesses, open ulcerations, sinus tracts, frictional pain, lymphedema, anal fissures, and arthritis. Depending on disease severity and type of pain, topical agents (lidocaine and anti-inflammatories), systemic nonsteroidal anti-inflammatories, acetaminophen, atypical anticonvulsants including gabapentin or pregabalin, and serotonin-norepinephrine reuptake inhibitors may be beneficial. Duloxetine is especially helpful if there is comorbid depression.[13]

Regardless of the stage of disease, treatment should include management of comorbidities that contribute to the development of or worsening of the disease process. Individuals who are above ideal weight or who smoke have more severe disease progression, so counseling and help with weight loss and smoking cessation are important components of treatment.

Treatment also involves avoidance of skin trauma. Eliminating tight and synthetic clothing, avoiding harsh products or cleaning tools (loofahs, washcloths, brushes) and avoiding adhesive dressings can be beneficial.  Soft dressings with clear petroleum jelly or non-occlusive dressings can be used to avoid further irritation to draining lesions.[14]

A critically important but often overlooked aspect of treatment involves the psychosocial aspect of the disease. Quality of life is diminished in individuals with this condition because of the associated pain, drainage, odor, and sensitive affected areas. Patients may become socially isolated, may have employment difficulties because of missed days of work when flares occur, and may have increased sexual or relationship dysfunction. Assurance that this condition is not contagious or the result of poor hygiene can be helpful. Counseling and support groups are often helpful additions to treatment plans.[15]

Differential Diagnosis

  • Follicular pyoderma (including folliculitis, furuncles, carbuncles)
  • Granuloma inguinale
  • Noduloulcerative syphilis
  • Tuberculous abscess
  • Actinomycosis
  • Lymphogranuloma venereum
  • Acne vulgaris 
  • Epidermoid, dermoid, pilonidal, or Bartholin cysts
  • Crohn’s disease (particularly with perianal involvement)

Prognosis

Prognosis is variable. There is no cure for this condition.   The prognosis worsens if there is a delay in diagnosis and treatment during the early stages of the disease, and also if comorbid conditions of smoking and obesity (if present) are not addressed and improved.[16]

Complications

Complications include both physical and psychological conditions.[17]  Physically, recurrence of lesions leading to abscesses, tracts, and scarring can cause chronic pain, limb contractures, and impaired mobility. Lymphatic obstruction can lead to peripheral lymphedema. Long-term effects of chronic inflammation can also occur, including anemia, hyperproteinemia, and amyloidosis, as well as and axial and peripheral arthropathy. In rare cases, a superimposed infection can lead to systemic illness ranging in severity. Squamous cell carcinoma can occur in the setting of HS, sometimes occurring up to 30 years after diagnosis. There is an associated increase in buccal and hepatocellular cancer based on observational data.

HS can have a psychological impact as well.  Combining chronic pain with drainage, odor, and deformity of skin appearance can lead to depression, social isolation, decreased relationship satisfaction, sexual dysfunction, decreased work productivity, and even suicide in extreme cases.[17]

Deterrence and Patient Education

Patient education involves reassurance that the condition is not infectious or caused by poor hygiene. Patients should report lesions as soon as they occur so that proper treatment can be initiated for both immediate relief and avoidance of chronic worsening of the condition. Individuals should also be counseled on lifestyle modifications including maintenance of healthy weight, smoking cessation, and avoiding skin trauma by wearing looser fitting clothing, avoiding abrasive cleansing and adhesive bandages. Education regarding risks and benefits of various treatments should be provided, with the most effective treatment for the current disease state offered.  Psychosocial education and treatment is an important component.

Pearls and Other Issues

  1. HS is a chronic, inflammatory skin disorder with lesions ranging from deep-seated, painful nodules, to abscesses with sinus tract formation, to dense fibronodular scarring.
  2. HS begins with obstruction of hair follicles, followed by rupture and subsequent inflammatory reaction. Infection does not cause HS.  It is not contagious, and is not the result of poor hygiene.
  3. Development of HS appears to have both hereditary and environmental influences. The strongest associated external influences are obesity and smoking.
  4. Treatment options include medications (topical and oral antibiotics, intralesional and oral steroids, hormone therapy, and immune modulators) and surgery ranging from lesion de-roofing to wide excision.
  5. HS can cause significant psychosocial distress because of pain, drainage, odor, and location of lesions.
  6. The best prognosis involves early recognition and aggressive treatment at early stages of the disease. Treatment includes psychosocial support.

Enhancing Healthcare Team Outcomes

HS is a complex condition with numerous comorbidities. An interprofessional approach is most effective in the management of this disease.[18]

Although HS is considered a dermatologic condition, individuals do not always present to the dermatology office with symptoms. Often family and internal medicine physicians, pediatricians, and obstetricians/gynecologists are the individual's first contact within the health care system. It is critical for primary care providers to recognize HS based on the morphology, location, and chronicity of lesions and begin the correct treatment early in the disease process. Depending on the severity of the disease and the training of the primary providers, they may treat independently or refer to specialists including dermatologists, surgeons, wound care, and pain management. Since there is a significant psychosocial impact associated with HS, the treatment team should also include providers of mental health support. If not provided at the primary care level, psychiatrists, psychologists, or counselors should be involved as needed.


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Hidradenitis Suppurativa - Questions

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What condition often is associated with hidradenitis suppurativa?



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A 30-year-old obese female has been diagnosed with Hurley stage II hidradenitis suppurativa with recurrent abscesses with sinus tracts and scarring, with widely separated lesions. She has tried and failed appropriate duration of topical clindamycin and oral tetracycline. She is not pregnant and has an IUD. Which of the following would be a logical next step?



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Which of the following skin conditions typically affects axillary areas?



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Which one of the following statements is not true about hidradenitis suppurativa?



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A 30-year old obese female smoker presents with recurrent, painful, nodular lesions in her right axilla. The nodules are connected by tracts that drain a purulent, malodorous material. What is the most likely diagnosis?



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Which of the following intervention sets would most likely improve the prognosis of an individual with hidradenitis suppurativa?



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Where is the primary pathology in hidradenitis suppurativa?



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Which is most likely associated with hidradenitis suppurativa?



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What do cultures from draining sinuses in hidradenitis suppurativa usually reveal?



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A young African female presents with a long history of recurrent painful lesions under her armpit. She says she initially just had a rash, which slowly evolved into large acne-like lesions. The lesions are painful to touch and often drain. She has been to many providers and always been given antibiotics. Her lesions have been present for at least six months. Examination reveals a dozen erythematous papules that are about 1 cm in diameter. There are some nodules that have a discharge and are tender to touch. After careful examination, the skin problem is graded at stage 2. What type of laser will most likely benefit this patient?



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A young African female presents with a long history of recurrent painful lesions under her armpit. She says she initially just had a rash, which slowly evolved into large acne-like lesions. The lesions are painful to touch and often drain. She has been to many doctors and always been given antibiotics. Her lesions have been present for at least 6 months. Examination reveals a dozen erythematous papules that are about 1 cm in diameter. There are some nodules that have a discharge and are tender to touch. Which gastrointestinal condition is frequently associated with this disorder?



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A young African female presents with a long history of recurrent painful lesions under her armpit. She says she initially had just a rash and then started to develop large acne-like lesions, which have become very painful. The lesions have been present for at least 6 months. She has been to many clinicians and only given antibiotics, which have not helped. Examination reveals dozens of erythematous papules that are about 0.5-1 cm in diameter. There are some nodules that have a discharge. This is a chronic inflammatory disorder associated with which one of the following?



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A young African female presents with a long history of recurrent painful lesions under her armpit. She says she initially just had a rash, which slowly evolved into large acne-like lesions. The lesions are painful to touch and often drain. She has been to many doctors and has always been given antibiotics. Her lesions have been present for at least 6 months. Examination reveals a dozen erythematous tender papules that are about 1 cm in diameter. There are some nodules that have a discharge and are very painful to touch. The dermatologist feels that this is a chronic inflammatory disorder of the apocrine glands. In patients with this disorder which of the following is the major cause of impairment in quality of life?



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A patient presents with boil-like tender nodules, sinus tracts, and drainage in the axillae, groin, and crease of the buttocks. What is the diagnosis?



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What of the following is not a risk factor for hidradenitis suppurativa?



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A 17-year-old female has had recurrent, painful suppurating lesions in the groin and axilla over the past two years. On exam, there are double-ended comedones. Which of the following could be considered as a first-line treatment?



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A 32-year-old overweight female presents to the clinic with tender nodular lesions in her axillae. The physician suspects hidradenitis suppurativa. Which of the following structures is most likely involved in the pathogenesis of hidradenitis suppurativa?



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A 35-year-old female who is obese presents with inframammary deep-seated, painful nodules, sinus tracts, and scarring from previous lesions and is diagnosed with hidradenitis suppurativa. In addition to medical and surgical treatment as indicated, what self-help recommendations should be given to the patient?



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A 52-year-old male has a deep-seated, painful, 1 cm nodular lesion in the right, retroauricular area. He has never had a similar lesion. It is not erythematous or warm. He reports that his mother always had similar lesions. A simple incision and drainage was not curative and cultures were negative. His condition improved, however, when he started taking finasteride for benign prostatic hypertrophy. You suspect hidradenitis suppurativa but your colleague states that this is very unlikely because of which of the following?



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A 25-year-old female who is obese presents to her primary care provider with a 2 cm diameter, deep-seated, painful nodule in the right groin. She recently spent time in a friend's hot tub. On exam, she is well appearing and afebrile. The nodule is not erythematous or currently draining. She has several scars in the groin from previous lesions. Her family history is positive for similar nodules occurring in her sister. What is the most likely diagnosis?



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Which of the following is true regarding hidradenitis suppurativa?



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Making a diagnosis of hidradenitis suppurativa requires which of the following?



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Hidradenitis Suppurativa - References

References

Woodruff CM,Charlie AM,Leslie KS, Hidradenitis Suppurativa: A Guide for the Practicing Physician. Mayo Clinic proceedings. 2015 Dec     [PubMed]
Miller IM,McAndrew RJ,Hamzavi I, Prevalence, Risk Factors, and Comorbidities of Hidradenitis Suppurativa. Dermatologic clinics. 2016 Jan     [PubMed]
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Clemmensen OJ, Topical treatment of hidradenitis suppurativa with clindamycin. International journal of dermatology. 1983 Jun     [PubMed]
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van der Zee HH,Boer J,Prens EP,Jemec GB, The effect of combined treatment with oral clindamycin and oral rifampicin in patients with hidradenitis suppurativa. Dermatology (Basel, Switzerland). 2009     [PubMed]
Kraft JN,Searles GE, Hidradenitis suppurativa in 64 female patients: retrospective study comparing oral antibiotics and antiandrogen therapy. Journal of cutaneous medicine and surgery. 2007 Jul-Aug     [PubMed]
Boer J,Nazary M, Long-term results of acitretin therapy for hidradenitis suppurativa. Is acne inversa also a misnomer? The British journal of dermatology. 2011 Jan     [PubMed]
Soria A,Canoui-Poitrine F,Wolkenstein P,Poli F,Gabison G,Pouget F,Viallette C,Revuz J, Absence of efficacy of oral isotretinoin in hidradenitis suppurativa: a retrospective study based on patients' outcome assessment. Dermatology (Basel, Switzerland). 2009     [PubMed]
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