Hidradenitis suppurativa

Definition

Hidradenitis suppurativa (hi-drad-uh-NI-tis sup-u-ra-TI-va) is a chronic skin inflammation marked by the presence of blackheads and one or more red, tender bumps (lesions). The lesions often enlarge, break open and drain pus. Scarring may result after several recurrences.

Considered a severe form of acne (acne inversa), hidradenitis suppurativa occurs deep in the skin around oil (sebaceous) glands and hair follicles. The parts of the body affected — the groin and armpits, for example — are also the main locations of apocrine sweat glands.

Hidradenitis suppurativa tends to start after puberty, persist for years and worsen over time. Early diagnosis and treatment of hidradenitis suppurativa can help manage the symptoms and prevent new lesions from developing.

Hidradenitis suppurativa of the armpit

Hidradenitis suppurativa of the armpit

Hidradenitis suppurativa usually appears as one or more red, tender bumps that fill with pus. It commonly occurs where oil (sebaceous) and apocrine sweat glands are found, such as the armpits (shown),...

Symptoms

Hidradenitis suppurativa commonly occurs around hair follicles where many oil and sweat glands are found, such as the armpits, groin and anal area. It may also occur in areas where skin rubs together, such as the inner thighs, under the breasts or between the buttocks. Hidradenitis suppurativa can affect a single area or multiple areas of the body.

Signs and symptoms of hidradenitis suppurativa include:

• Blackheads. Small pitted areas of skin containing blackheads, often appearing in pairs or a "double-barreled" pattern.
• Red, tender bumps. These bumps, or lesions, often enlarge, break open and drain pus. The drainage may have an unpleasant odor. Itching, burning and excessive sweating may accompany the bumps.
• Painful, pea-sized lumps. These hard lumps, which develop under the skin, may persist for years, enlarge and become inflamed.
• Leaking bumps or sores. These open wounds heal very slowly, if at all, often leading to scarring and the development of tunnels under the skin.

Hidradenitis suppurativa often starts at puberty with a single, painful bump that persists for weeks or months. For some people, the disease progressively worsens and affects multiple areas of their body. Other people experience only mild symptoms. Excess weight, stress, hormonal changes, heat or excessive perspiration can worsen symptoms.

When to see a doctor
Mild cases of hidradenitis suppurativa may be treated with self-care measures. But if the condition doesn't improve in one to two weeks, appears in several locations, recurs often or is painful, consult your doctor or a dermatologist. Usually, medical treatments — such as prescription medications or surgery — are necessary to manage the problem.

Hidradenitis suppurativa of the armpit

Hidradenitis suppurativa of the armpit

Hidradenitis suppurativa usually appears as one or more red, tender bumps that fill with pus. It commonly occurs where oil (sebaceous) and apocrine sweat glands are found, such as the armpits (shown),...

Causes

Hidradenitis suppurativa develops when the oil (sebaceous) glands and hair follicle openings become blocked with fluid, dead skin cells and other matter released from surrounding apocrine sweat glands. When these substances mix with the oil from the sebaceous glands, they can become trapped and push into surrounding tissue. Bacteria can then trigger infection and inflammation.

It's not known why this blockage occurs, but a number of factors — including hormones, genetics, cigarette smoking and excess weight — may all play a role.

Sometimes hidradenitis suppurativa occurs with other diseases, such as Crohn's disease or Graves' disease.

Hidradenitis suppurativa

Hidradenitis suppurativa

Hidradenitis suppurativa occurs around oil (sebaceous) glands, apocrine sweat glands and hair follicles. Inflammation occurs when oils and other skin products become trapped and push into surrounding ...

Risk factors

Hidradenitis suppurativa occurs equally among all races and ethnic groups. But based on what's currently known, the following factors appear to be more commonly associated with the disease:

• Being female. Women are more likely to develop hidradenitis suppurativa. Why this occurs is unknown.
• Being between puberty and age 40. Hidradenitis suppurativa rarely affects children, but can occur in adults older than 40.
• Family history. Having a family history of hidradenitis suppurativa increases your risk of developing the disease.

Complications

Hidradenitis suppurativa often causes complications when the disease is persistent and severe. These complications include:

• Sinus tracts or tunnels that connect and form a network under the skin. The tracts prevent the sores from healing and cause more sores to develop.
• Scars and skin changes. Severe hidradenitis suppurativa may leave thick, raised scars, pitted skin or patches of skin that are darker than normal (hyperpigmentation).
• Restricted movement. The disease may cause limited or painful movement, especially when it affects the armpits or thighs.
• Cellulitis. This potentially serious bacterial infection appears as an area of swollen, red skin that feels hot and tender and that may spread rapidly. Although the initial infection may be superficial, it eventually can affect the tissues underlying your skin or spread to your lymph nodes and bloodstream.

Preparing for your appointment

You're likely to start by seeing your family doctor or a general practitioner. However, in some cases when you call to set up an appointment, you may be referred immediately to a specialist in skin diseases (dermatologist).

Because appointments can be brief, and because there's often a lot to cover, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do
Write down all your signs and symptoms and when they first occurred. Record how long the lesions lasted and if any recurred.

Make a list of all medications, including vitamins, herbs and over-the-counter drugs, that you're taking. Even better, take the original bottles and a written list of the dosages and directions.

If possible, take along a family member or friend. It can be difficult to absorb all the information provided to you during an appointment. The person who accompanies you may remember something that you forgot or missed.

Write down questions that you want to ask your doctor. Don't be afraid to ask questions or to speak up when you don't understand something your doctor says. Start with the problems that concern you most. If you run out of time, ask to speak with a nurse or physician's assistant or leave a message for your doctor.

If you have symptoms of hidradenitis suppurativa, questions you may want to ask include:

• What is likely causing my symptoms?
• What are other possible causes for my symptoms?
• What tests do I need to confirm the diagnosis?
• Is this condition temporary or chronic?
• What is the best course of action?
• What are the alternatives to the primary treatment approach that you're suggesting?
• Is there a generic alternative to the medicine you're prescribing me?
• What if I just wait to see if my signs and symptoms go away on their own?
• Do you have any literature on this condition? Is there a website you can recommend where I can learn more?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment.

What to expect from your doctor
Your doctor is likely to ask you a number of questions, such as:

• When did your symptoms start?
• Did they come on suddenly or gradually?
• What did the lesions look like when they started?
• Are your symptoms painful?
• What, if anything, makes them better?
• What, if anything, makes them worse?
• Do you have other symptoms that started about the same time?
• What medications do you take?

Tests and diagnosis

To make a diagnosis, your doctor may ask about your symptoms and medical history, examine your skin, and order blood tests. If pus or drainage is present, your doctor may send a sample of the fluid to a laboratory for testing. This test is known as a culture. Such tests may be necessary to rule out other skin conditions, such as tuberculosis of the skin.

Treatments and drugs

There is no cure for hidradenitis suppurativa. But early treatment can help manage the symptoms and prevent new lesions from developing.

Treatments depend on the extent of the affected areas and whether the sores are painful or infected. Mild cases can be treated with self-care measures, including warm compresses and regular washings with antibacterial soap. Moderate cases may require medications, such as those you rub on the affected areas (topical medications) or those you take by mouth (oral medications). Possible medications include:

• Antibiotics. Antibiotics taken for a long time early in the disease help fight infection and may prevent future outbreaks or prevent the disease from worsening.
• Oral retinoid medications. Taken to stop oil gland functions, these medications can help prevent the plugging of the hair follicles.
• Nonsteroidal anti-inflammatory drugs. These can help alleviate pain and swelling.
• Corticosteroids or immunosuppressant drugs. These may help reduce inflammation, especially in the early stages of hidradenitis suppurativa.
• Tumor necrosis factor (TNF)-alpha inhibitors. These medications show promise in the treatment of hidradenitis suppurativa. They can be used only in the short term, however, due to the risks involved with longer use.

For severe or persistent cases or for deep lesions, surgery may be necessary.

• Incision and drainage. Surgical drainage or removal of the lesions may be an option when the disease involves a single small area. However, this treatment won't prevent the disease from returning and is generally used for short-term relief.
• Uncovering the tunnels or tracts. Cutting away skin and flesh that cover any tunnels or tracts can increase healing of the lesions and minimize scarring. This doesn't prevent the disease from returning in the treated area or another area of the body, however.
• Surgical removal. Surgical treatment of recurrent or severe symptoms involves removal of all involved skin followed by direct closure with skin flaps or with skin grafting (removing skin from one area of your body and attaching it to another). Full surgical removal of the affected areas can treat the disease that is present but doesn't prevent the disease from occurring in other areas.

Obesity, incomplete removal and ongoing skin infections can increase the chances that hidradenitis suppurativa returns, even after surgical treatment.

Lifestyle and home remedies

The following suggestions may help relieve discomfort, speed healing and prevent the infection from spreading:

• Apply warm compresses. A warm washcloth or compress can help reduce swelling.
• Keep the affected area clean. Gently wash the affected areas with antibacterial soap. After washing, apply an over-the-counter antibiotic.
• Wear loosefitting clothes. Loose clothes and underwear can help prevent skin irritation, while tightfitting, synthetic clothes may irritate your skin.
• Avoid shaving. Shaving can irritate affected areas.
• Don't smoke. No scientific studies have been done on the effects of smoking cessation on hidradenitis suppurativa. However, stopping smoking has many health benefits and may improve the course of the disease.
• Lose weight. Excess weight increases the number of areas where skin rubs together — for example, between skin folds — causing friction, increased perspiration and bacterial growth. Though weight loss won't cure the disease, it may improve symptoms.

Alternative medicine

Zinc gluconate supplements (zinc salts) taken daily may help reduce inflammation and prevent new outbreaks.

Coping and support

For many, hidradenitis suppurativa is very distressing. This condition can be painful, unsightly and, if the lesions are draining, foul smelling. The ongoing, persistent nature of the disease and the treatment challenges only add to the burden. You might feel embarrassed or anxious about your symptoms and become withdrawn or self-conscious. You may be frustrated or upset by other people's reactions.

If you're having difficulty coping, you may find some of the following suggestions helpful:

• Educate yourself about hidradenitis suppurativa. The more you know, the better prepared you'll be to deal with complications or recurrences. Besides talking to your doctor, you may want to talk to a counselor or medical social worker. Or you may find it helpful to talk to other people with hidradenitis suppurativa.
• Follow your doctor's recommendations. If your doctor recommends certain treatments or lifestyle changes, be sure to follow them. Ask questions if anything is unclear.
• Maintain a strong support system. Family and friends can help you tremendously as you go through this difficult time. Sometimes, though, you may find the concern and understanding of other people with hidradenitis suppurativa especially comforting. Go online to connect with other people living with the condition.