Hidradenitis Suppurativa

Hidradenitis Suppurativa (HS), also known as acne inversa or Verneuil's disease, is a chronic dermatological condition characterised by the formation of painful, inflamed lumps under the skin. These lumps can break open and release fluid or pus, leading to scarring. HS commonly affects areas with hair follicles and apocrine (sweat) glands, such as the underarms, under the breasts, perineum, buttocks, and groin.

The condition can significantly impact daily activities and quality of life due to severe pain and restricted movement.

Hidradenitis suppurativa (Hurley's stage II) in the left armpit

Signs and Symptoms

HS manifests as multiple inflamed and swollen skin lesions, which are typically painful and can break open, releasing fluid or pus. Scar tissue remains after healing. The disease is classified into three stages:

1. Stage I: Solitary or multiple isolated abscesses without scarring or sinus tracts.
2. Stage II: Recurrent abscesses, single or multiple widely separated lesions, with sinus tract formation.
3. Stage III: Diffuse or broad involvement across a regional area with multiple interconnected sinus tracts and abscesses.

A case of hidradenitis suppurativa

Hidradenitis Suppurativa can take the form of growths on the skin that are extremely painful and debilitating.

Causes

The exact cause of HS is unknown, but it is believed to involve a combination of genetic and environmental factors. Genetic predisposition is suggested, as about a third of patients have a family history of the disease. Obesity, smoking, tight clothing, and stress are considered exacerbating factors. The condition is not caused by poor hygiene or infection. It is thought to result from blocked hair follicles or sweat glands, leading to inflammation and abscess formation.

Diagnosis

Early diagnosis of HS is very important to prevent tissue damage. Diagnosis is based on clinical symptoms, and a delay in diagnosis is common due to a lack of awareness among healthcare professionals. Staging systems like Hurley's and Sartorius' are used to classify the severity of the disease and guide treatment.

Hidradenitis suppurativa stage III on abdomen: Skin is red and inflamed, constantly draining a malodorous blood/pus mixture. Pain is severe.

Treatment

Treatment of HS depends on the severity of the condition and includes lifestyle changes, medications, and surgical interventions.

Lifestyle

Warm baths, weight loss, and smoking cessation are recommended for milder cases.

Medication

• Antibiotics: Used for their anti-inflammatory properties, with a combination of rifampicin and clindamycin being particularly effective.
• Corticosteroids: Intralesional injections can be useful for localised disease.
• Antiandrogens: Hormonal therapies with antiandrogenic medications like spironolactone and cyproterone acetate have shown effectiveness.
• Biologics: Adalimumab and secukinumab are approved for treating moderate to severe HS.
• Other Medications: Zinc and nicotinamide have shown efficacy in mild to moderate cases.

Surgery

For chronic and severe cases, wide surgical excision is the treatment of choice. Techniques like Skin-Tissue-sparing Excision with Electrosurgical Peeling (STEEP) and laser hair removal may also be used.

Hidradenitis Suppurativa Stage III. Open lesions are extremely painful.

Laser Hair Removal

The 1064-nm wavelength laser has shown improvement in HS lesions, providing another option for managing the disease.

Prognosis

In severe stages, HS can lead to complications such as squamous cell carcinoma, anaemia, multilocalized infections, and sepsis. The condition also has a significant impact on mental health, leading to higher rates of depression, anxiety, and suicide attempts.

Hidradenitis Suppurativa Stage III. Inflamed lesion.

Epidemiology

The prevalence of HS varies worldwide, estimated at 0.1% in the USA and around 1% in Europe. Women are more commonly affected than men in North America and Europe, while in South Korea, men are more frequently diagnosed. The condition is most prevalent in individuals in their 40s and 50s.

History

HS was first described by Velpeau between 1833 and 1839. Verneuil later coined the term hidrosadénite phlegmoneuse, and subsequent research has furthered understanding of the disease's pathogenesis and treatment options.

Micrograph of hidradenitis suppurativa: Sinus tracts [(A), arrow], active inflammation, and rupture [(B), asterisks] of the follicular epithelium with “floating” hair fragments (B), arrow. Subsequently, a secondary inflammatory response is induced with influx of numerous neutrophils [(C), arrows] and granulomatous foreign body reaction with giant cells [(C), asterisks].

Self-assessment MCQs (single best answer)

What is another name for Hidradenitis Suppurativa (HS)?

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Which areas are commonly affected by HS?

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HS is classified into how many stages?

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What is the primary symptom of HS?

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Which factor is NOT considered to exacerbate HS?

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Which medication is commonly used for its anti-inflammatory properties in HS treatment?

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What is a possible severe complication of HS?

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What is the estimated prevalence of HS in Europe?

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Which laser wavelength is shown to improve HS lesions?

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Who first described Hidradenitis Suppurativa?

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