Core Dermatology Diagnoses / CategoriesInflammatory

Hidradenitis Suppurativa

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Publish date: Posted on
Last updated: November 27, 2024

Keywords #
  • hidradenitis suppurativa
  • acne inversa
Diagnosis #

Hidradenitis suppurativa (HS) is a chronic inflammatory and follicular occlusive disease involving intertriginous, apocrine gland-baring areas such as the axillae, groin, and inframammary folds. Patients initially present with inflammatory papules or pustules. Over time, lesions can progress to become recurring abscesses, painful nodules, and sinus tracts with significant scarring. Each individual disease course is highly variable in severity and phenotypic expression.

Key Concepts #
  • Hidradenitis suppurativa is a chronic, painful, relapsing and remitting inflammatory disease involving the follicular pilosebaceous unit.
  • Disease severity and progression varies from person to person. The Hurley staging system is often used to estimate disease severity which takes into consideration number of lesions, scarring, and number of sites involved.
  • There is no “one size fits all” treatment approach to disease management.
  • HS can have a profound, negative psychological impact and emotional toll on patients with the disease[1].
Epidemiology #

HS has prevalence estimates anywhere from 0.05 to 4.0% [2,3]. HS is more common in females and African Americans. It most commonly presents in the second and third decades of life [4]. HS rarely develops in pre-pubescent children indicating hormones as a potential component of disease pathogenesis.

Clinical Features #
  • Painful and erythematous papulonodules, abscesses, comedones, and sinus tracts. Significant scarring may be present as well.
  • Lesions are typically present in the apocrine gland bearing regions of the groin, axillae, inframammary and gluteal folds. They can also present in regions of constant friction like waistbands, abdominal folds, and bra straps.
Differential Diagnoses #
Diagnostic Workup #
Diagnosis is usually based on clinical presentation. The location and chronicity of lesions are key. HS appears to be associated with elevated BMI and smoking tobacco[5]. Care should be taken to rule out any gastrointestinal symptoms as Crohn’s disease can sometimes present with lesions in the anogenital region. Bacterial cultures are not necessary. Detailed family history can be beneficial. Reported flares around the patient’s menstrual period may further support the diagnosis.
Treatment #

Treatment for hidradenitis suppurativa is varied and selection of treatment modality usually depends on severity and extent of disease burden. Typical first line treatment options for Hurley stage 1 and 2 include oral antibiotics and topical clindamycin. Although HS is not thought to be caused by bacterial infections, antibiotics have been shown to be useful in disease management [6]. Other treatment options include hormonal manipulation in women through combined oral contraceptives and spironolactone. The use of Metformin, a drug usually used in the treatment of diabetes has shown efficacy in some patients[9]. For acute lesions, intralesional corticosteroids are useful to calm inflammation and decrease pain. Incision and drainage is reserved only for acute pain relief as lesions frequently recur. For Hurley stages 2 and 3 treatment is usually escalated to involve the use of biologic medications such as adalimumab or infliximab and wide surgical excision[7, 8]. Local excision may be helpful for limited disease, but lesions frequently recur. Usually a combination of strategies is necessary for disease control.

Slide Viewer #
https://utahderm.med.utah.edu/image-viewer/
References #
  1. Kouris, Anargyros et al. “Quality of Life and Psychosocial Implications in Patients with Hidradenitis Suppurativa.” Dermatology (Basel, Switzerland) vol. 232,6 (2016): 687-691.
  2. Cosmatos, Irene et al. “Analysis of patient claims data to determine the prevalence of hidradenitis suppurativa in the United States.” Journal of the American Academy of Dermatology vol. 68,3 (2013): 412-9.
  3. Jemec, GB et al. “The prevalence of hidradenitis suppurativa and its potential precursor lesions.” Journal of the American Academy of Dermatology vol. 35,2 Pt 1 (1996): 191-4.
  4. Garg, Amit et al. “Sex-and Age-Adjusted Population Analysis of Prevalence Estimates for Hidradenitis Suppurativa in the United States.” JAMA dermatology vol. 153,8 (2017): 760-764.
  5. Revuz, Jean E et al. “Prevalence and factors associated with hidradenitis suppurativa: results from two case-control studies.” Journal of the American Academy ofDermatologyvol. 59,4 (2008): 596-601.
  6. Jemec, G B, and P Wendelboe. “Topical clindamycin versus systemic tetracycline in the treatment of hidradenitis suppurativa.” Journal of the American Academy of Dermatology vol. 39,6 (1998): 971-4.
  7. Kimball, Alexa B et al. “Adalimumab for the treatment of moderate to severe Hidradenitis suppurativa: a parallel randomized trial.” Annals of internal medicinevol. 157,12 (2012): 846-55.
  8. Grant, Annika et al. “Infliximab therapy for patients with moderate to severe hidradenitis suppurativa: a randomized, double-blind, placebo-controlled crossover trial.” Journal of the American Academy of Dermatologyvol. 62,2 (2010): 205-17.
  9. Jennings, Lorraine et al. “Metformin use in hidradenitis suppurativa.” The Journal of dermatological treatment vol. 31,3 (2020): 261-263.
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