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Hidradenitis suppurativa (HS) or acne inversa is a noncontagious but chronic dermatological ailment marked by the appearance of painfully swollen lesions, typically in the areas where the skin rubs against itself or the clothes you wear.
This condition usually starts around puberty and is more prevalent in women than in men.
HS occurs due to the blockage of sweat glands and hair follicles, which then leads to the development of inflammatory lesions in the affected area. It is suggested your genes may also play a role in the development of this condition, considering it runs in the family in several patients.
The following factors do not directly cause HS but can definitely contribute to its onset and progression:
- Anxiety and depression
- Certain hormonal imbalances that overactivate the apocrine sweat glands, such as the ones that occur before menstrual periods
- Gastrointestinal disorders such as Crohn’s disease and ulcerative colitis, which can sometimes trigger severe symptoms that require medical attention such as persistent diarrhea or stomach pain, bloodied stools, and unexplained weight loss
- Cigarette smoking
- Being overweight (1)
- Wearing tight clothes
There are three stages (called Hurley stages) of HS:
- Stage I includes blackheads and bumps with little scarring.
- Stage II includes recurrent abscesses with scarring and sinus tract formation.
- Stage III involves a large area of the skin with multiple interconnected sinus tracts and abscesses.
The most characteristic symptom of HS is red, inflamed, painful bumps that:
- Usually develop in the armpits, below the breasts, between the buttocks, on the inner thighs, and in the nether regions (2)
- Tend to come and go
- Often itch or burn
- May ooze out “pus-like” fluid, which requires daily dressing
- May be connected through tunnels that form under the skin
- May change the color of the affected skin
- May leave a scar
It is important to seek treatment for HS to avoid complications. The following are the treatment options:
- Antibacterial lotions and washes are recommended to limit the spread of infection on the skin.
- Oral and topical retinoids are prescribed to inhibit the activity of the sebaceous glands and reduce abnormal keratinization. Retinoids are derivative compounds of vitamin A that are known to promote skin regeneration and curb inflammation, (3) both of which help calm and heal HS symptoms.
- Topical antibiotics along with benzoyl peroxide are a commonly prescribed combination for treating HS. They stop the bacterial overgrowth on the skin to keep the infection under control and speed up recovery. Clindamycin (1%) is a popular antibiotic ointment that has proven quite effective when used along with a benzoyl peroxide wash. (4) However, these antibacterial agents can severely dry out your skin, so you must use an appropriate moisturizer after them.
- Hormone pills such as oral contraceptives may help correct the hormonal imbalance that is triggering or exacerbating HS symptoms. This intervention has delivered good results in some women.
- Oral or intravenous steroids are prescribed for severe flare-ups. They help bring down the inflammation that is irritating the skin and exacerbating HS symptoms. (4) Note that steroid overuse causes skin thinning and may harm the body in other ways, so it is important that you stick to your doctor-prescribed dosage.
- Corticosteroid injections are useful for treating painful HS nodules when they are still in their early stages of formation and devoid of any infection. But this intervention does not work on fistulas that form in the later stages of the disease. The steroid is injected directly into the lesion to suppress the inflammation and relieve the discomfort. (5)
- Biologics are medicines that are given as injections or infusions. If you have many HS wounds or lesions, this medication may be prescribed. (6)
- Electrosurgery involves using controlled electric heat to dissolve the HS lesions. It is generally preferred over the conventional wide-excision surgery as it is much less invasive. (7)
- Excision (cutting out) of the lesions followed by skin grafting involves surgically removing large areas of the infected skin and scar tissue and replacing them with healthy skin taken from an unaffected part of the body. This has proven to be a safe and effective therapy. (8)
- Unroofing involves uncovering the tunnels that form under the skin between different lesions by removing the overlying skin tissue. It is typically recommended for moderate to severe HS and works for both small and large lesional units. (9)
- Laser surgery is a minimally invasive procedure wherein the lesions are vaporized by exposing them to a laser beam. This intervention is effective for moderate and localized HS but is usually preceded by medication to get the disease under control. The perks of this technique are that it offers speedy post-treatment recovery and involves minimal risk of complications. (10)
To diagnose HS, the dermatologist will evaluate your symptoms and medical history, conduct a close physical examination, and order blood tests if needed. If there is drainage from the lesions, the doctor may order a swab test of the pus or fluid to look for signs of infection.
The following measures are helpful in the management of HS:
- Wear soft, flowy fabrics that don’t cling to your body and cause extra sweating or rub against your skin, such as cotton.
- Seek professional counseling if you feel isolated and depressed.
- Wash the affected skin with a medicated cleanser that does not disrupt your skin’s normal pH, ideally using your hands rather than a washcloth or sponge that can further irritate or rupture the lesions.
- Ask your doctor about safe hair removal options, especially for your underarms and pubic area as this may help prevent breakouts.
- Eat foods that are rich in omega-3 fatty acids, which help curb the underlying inflammation to soothe your irritated skin. Some of your best options are berries, broccoli, tomatoes, leafy green vegetables, walnuts and pecans, and seafood such as salmon, tuna, and mackerel.
- Try to keep your skin dry and sweat-free at all times to prevent new lesions from forming.
Avoid HS flare-ups by following these tips:
- Lose excess weight to get rid of skin folds, which will inadvertently reduce chafing, sweat buildup, and the risk of bacterial growth – three factors that can induce and exacerbate HS. This single step will not cure your condition but will surely bring it under control and minimize recurrent episodes.
- Avoid shaving near a breakout as the razor can irritate your skin. Laser hair removal is a safer alternative, but you must consult with your dermatologist before trying any hair removal technique.
- Quit smoking as it can make your condition worse.
- Manage your stress levels by keeping yourself in a calm environment. Consider meditation or even just 15 minutes of alone time. The more relaxed you are, the more your symptoms will improve.
- Avoid activities that make you sweat a lot such as rigorous workouts, too much sun exposure during summer, or sitting too close to the fireplace or heater.
HS can give rise to the following complications, especially in cases of delayed or poor treatment:
- Psychological stress – The condition can make you self-conscious about your appearance and can hamper your confidence levels.
- Cellulitis – Cellulitis is a severe form of infection that occurs when the bacteria travel from the surface to the deeper layers of the skin, and it may spread locally or systemically.
- Limited activity – It can be very painful to move your limbs, especially when the lesions develop in the armpit or on your inner thighs.
- Skin cancer – This complication is quite rare but has been reported in very severe long-term HS.
- Scarring of skin
- Lymphatic involvement and lymphedema – These are rare complications.
When to See a Doctor
See your doctor if:
- You are stressed or embarrassed about the HS lesions.
- Your lesions hurt a lot.
- The redness, swelling, or fluid leaking from your lesion gets worse, which points to an infection.
- You have diabetes or other immune-suppressive diseases.
- Your symptoms come back within weeks of treatment.
What will happen if HS is not treated early?
If left untreated, HS may lead to a continuous cycle of outbreaks that could get progressively worse and cause scarring once the lesions subside.
Fistulas are hollow tubes that form under the skin linking the various lesions in the area, mainly due to this continuous healing and scarring. Once formed, fistulas can be extremely painful and typically need surgery to heal.
How can I reduce pain during flare-ups?
If you have a severe breakout with painful lesions, see a doctor right away. Applying heat to the affected region might help provide fast relief by reducing the underlying skin inflammation. Make a warm compress by soaking a clean washcloth in warm water and then place it on the irritated skin for 10 minutes.
Hidradenitis suppurativa is a skin condition that creates painful, deep abscesses in areas where the skin rubs together. Oral antibiotics, biologics, and surgery are all options for treating flare-ups, which if not managed properly can give way to recurrences and scarring.
Seeking prompt medical treatment for the condition when it is still in the early stages leads to speedy and easier recovery with minimal skin damage. Delayed treatment, on the other hand, can pave the way for serious complications.