Hidradenitis Suppurativa

What Is Hidradenitis Suppurativa?

Hidradenitis suppurativa (HS) is a condition that causes painful bumps under your skin in the hair roots near some of your sweat glands. It’s also known as acne inversa.

The bumps can get infected. When that happens, pockets form under your skin and fill with pus. They can smell bad when they break open. They can also leave scars.

There's no cure for HS, but treatments and lifestyle changes can bring some relief and cut down on flare-ups.

Because this condition lasts a long time, it can be frustrating, and it can take an emotional toll on you. Make sure you get the support you need.

Causes

hidradenitis suppurativa in armpit

Doctors aren't sure what causes hidradenitis suppurativa, but it’s probably tied to your genes and to things in the world around you.

It's more common in women than in men. It’s also more likely if you’re overweight, if you smoke, and if you’ve had acne. About a third of people who get HS have a relative with it.

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The skin problems start when hair follicles get blocked. You often get the first symptoms in your teens or 20s.

You don’t get HS because you don’t wash enough, because you use deodorants or powders, or because you shave your underarms. You also can't catch it from someone else or give it to another person.

Symptoms

HS usually affects both sides of your body. You can get the bumps in one place or in several areas at once.

The first warning sign might be a single painful bump that gets inflamed. It can last days or months. You could have repeated outbreaks of a single bump in the same location or the same general area.

Besides turning into pockets of pus, the bumps can be itchy. Your skin might have small pitted areas with blackheads.

Some people get tunnels under their skin, called sinus tracts, which connect different areas of HS outbreaks.

The bumps and leaky pockets can go away and come back. In severe cases, they don't fully heal.

Common Sites

The blockages usually happen in areas where you have hair or where your skin rubs together, such as:

  • Under your arms
  • In your groin
  • Between your buttocks
  • Between your thighs
  • Under your breasts
  • In the folds of your stomach
  • On the nape of your neck
  • Behind your ears

Diagnosis

Your doctor will check your skin and make a diagnosis based on where the bumps and pockets are and how often you have them.

They may also ask you things like:

  • How long ago did your symptoms begin?
  • Are they painful?
  • Have you had these symptoms before?
  • Have any close relatives had this problem?

You probably won’t have tests unless your doctor needs to rule out other kinds of infections. Then, they’ll take a sample of pus and send it to a lab for testing.

Questions for Your Doctor

  • How mild or severe is my hidradenitis suppurativa?
  • What treatments are available? Which do you recommend?
  • Should I take an antibiotic? What about other medications?
  • Could these medications cause side effects?
  • Will I need surgery?
  • What lifestyle changes should I make to improve my illness?
  • Should I lose weight?
  • If my symptoms get worse, when should I call you?
  • Will the disorder go away on its own?

Stages

HS is divided into three stages, based on how severe it is, called Hurley stages.

  • Hurley stage I: A single bump with no sinus tracts
  • Hurley stage II: More than one bump but little tunneling
  • Hurley stage III: Multiple bumps with a lot of sinus tracts and scars, involving an entire area of your body

Treatment

Your treatment will be based on how severe your case is. You and your doctor might have to try multiple treatments to find the one that works best for you.

Treatments include:

Warm compresses. You might try this first if your case is mild. Run a clean washcloth under hot water and hold it on your skin for 10 minutes.

NSAIDs(nonsteroidal anti-inflammatory drugs). These over-the-counter medicines can ease your pain and help manage swelling. They include:

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Antibiotics. These medications fight infections. You can swallow them as a pill, or you can use a cream, ointment, cleanser, wash, or gel on your skin.

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At first, you may use doxycycline or minocycline for 2 to 3 months. If that doesn't help, your doctor may suggest a combination of clindamycin and rifampin (Rifadin, Rimactane).

Corticosteroids. Your doctor injects these medicines into the bumps. They can ease inflammation, pain, and swelling. You usually get these shots once a month for up to 3 months. If your case is severe, your doctor may recommend that you take steroid pills by mouth.

Oral retinoids. Your doctor may suggest a retinoid medication in a pill, such as acitretin (Soriatane) or isotretinoin (Accutane). Both can improve severe cases of HS.

Topical resorcinol. This is a cream that you put on inflamed areas of your skin. It has chemicals that peel the skin.

Hormone therapy. Some women find that their condition gets better if they take birth control pills or a drug called spironolactone.

Biologics. These medications work on your immune system, your body's defense system against germs. You take them by getting a shot, either at the doctor's office or at home. Or you may need to get the meds through an IV in your veins. This is done at a clinic or hospital.

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These drugs include:

  • Adalimumab (Humira). This medicine is the only one approved by the FDA to treat HS.
  • Infliximab (Remicade). The FDA hasn’t approved this for HS, but doctors still use it.
  • Anakinra, canakinumab, and ustekinumab. These medications may help some people with severe or hard-to-treat HS. Researchers are studying how well they work.

Biologics can clear up HS for a long time, but they can also have serious side effects, so doctors use them only for severe cases.

Other medications. These include:

  • Metformin (Glucophage). Doctors use this to treat adult-onset diabetes and metabolic syndrome. It may also help patients with HS.
  • Methotrexate (Xatmep). It is a pill, shot, or IV that controls the inflammation of psoriasis and other medical conditions, including some cancers. It works on your immune system and may help control HS in some people.

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Surgery. If your bumps grow deep into your skin, you might have a surgical procedure. If you're having problems in a small area, your doctor can cut open pockets to drain pus. This gives you short-term relief.

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In a procedure called deroofing, your doctor turns deep, painful bumps and pockets into scars that won’t hurt. It's an option if you have painful bumps that come back over and over.

Another type of surgery involves cutting out skin in the problem spots. Afterward, your doctor will do a skin graft. They take skin from another part of your body and use it to cover the area where you had the operation.

Laser surgery is another option to clear new, deep bumps. It destroys hair follicles, the shafts in your skin where hair grows. You may need several treatments.

Surgery can help with stubborn or severe cases of HS, but for some people, it may come back in the same area or somewhere else.

Lifestyle Changes

Try these tips to make your HS less severe and slow outbreaks.

Lose extra weight. This can ease your symptoms by making your skin rub together less.

Quit smoking. Not only does this cut your risk of cancer and heart disease, it can make your HS less severe. Talk to your doctor about programs that can help you break the habit.

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Don’t shave trouble spots. This can keep you from irritating your skin. Ask your dermatologist about other ways to get rid of unwanted hair.

Wear loose-fitting clothes. Outfits that are tight can cause your skin to rub, making your flare-ups worse.

Stay cool. You can get flare-ups when you get too warm and sweat. But be careful about using deodorants, which can sometimes irritate your skin. Ask your dermatologist for suggestions about one that won't cause problems.

Keep clean. Wash HS areas gently every day with your fingers. Scrubbing with a washcloth or brush can irritate your skin. Use an antibacterial soap, which can help get rid of odor.

Use the right bandage. If a pocket is leaking, cover it with a bandage that doesn't stick to the bump. Use plenty of petroleum jelly on the gauze that covers the area. Avoid using adhesive tape as much as possible.

Complications

HS that is severe or isn’t treated can have complications over time, including:

Outlook

HS can last for years, but early treatment can help you feel better and lower the risk of flare-ups.

In severe cases, hidradenitis suppurativa can get worse and cause scars. Surgery can help, although the disease comes back about one-third of the time. It's still important to keep up with lifestyle changes that can make you feel better.

Turn to people you trust to give you the backing you need while you get treated. You might join a support group where you can talk freely with people who understand your situation. Ask your doctor about how to find a group near you.

Talk to your close family and friends about your condition, or consider seeing a professional counselor. They can help make sure you don't let your skin problems keep you from enjoying an active social life.

You can learn more about your condition on the website of the Hidradenitis Suppurativa Foundation.

WebMD Medical Reference Reviewed by Hansa D. Bhargava, MD on October 02, 2020

Sources

SOURCES:

American Academy of Dermatology: "Hidradenitis Suppurativa: Diagnosis, Treatment, and Outcome," "Hidradenitis Suppurativa: Tips for Managing."

FamilyDoctor.org: "Hidradenitis Suppurativa."

Medscape: "Hidradenitis Suppurativa."

UpToDate: "Hidradenitis Suppurativa," “Hidradenitis suppurativa: Pathogenesis, clinical features, and diagnosis.”

Hidradenitis Suppurativa Foundation: “What is Hidradenitis Suppurativa?”

Genetic and Rare Diseases Information Center: “Hidradenitis suppurativa.”

Cleveland Clinic: “Hidradenitis Suppurativa.”

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