What is Hidradenitis Suppurativa?

Hidradenitis suppurativa (HS) is also known as acne inversa. Many patients mistake it for acne or folliculitis, and attempt to treat it as such, wondering why it doesn’t seem to go away. In this article we will discuss the symptoms, causes, and treatments for hidradenitis suppurativa in the following sections.

Why does your patient have Hidradenitis Suppurativa?

Hidradenitis suppurativa (HS), or acne inversa, is a chronic inflammatory skin disease that manifests as recurrent, and often painful draining nodules and tracts. Unlike acne, which tends to affect the face and upper torso, HS most commonly affects the skin folds such as the armpits, inframammary folds, buttocks, and groin.1,2 Although the exact cause of the disease is unknown, it is suspected to be caused by the blockage of hair follicles by skin debris, resulting in inflammation, rupture, and possibly scarring.3

What causes the disease?

Inflammation

The body’s inflammatory response to things such as bacteria and skin debris in the hair follicles is thought to be the major driver in hidradenitis. It is often seen in association with other inflammatory diseases such as Crohn’s disease and inflammatory arthritic diseases. A defective skin barrier that allows for deeper penetration of irritants and bacteria can lead to worsening inflammation, and more severe disease.3

Genetics

About a third of patients with hidradenitis suppurativa report a family history of the disease. In patients who develop the disease earlier in life, more than half report a family history of hidradenitis suppurativa.4 Mutations that lead to abnormal inflammatory responses may be associated with the disease.5-8

Hormones

Hidradenitis suppurativa is more common in women, with reports of flare-ups during the pre-menstrual and menstrual phase of the menstrual cycle.3 There appears to be a link between excess androgens, such as testosterone, and HS in some patients. Medications that decrease androgen levels have been shown to decrease disease severity.9-11

What Medical Treatments Are There for Hidradenitis Suppurativa?

There are a variety of treatments available for Hidradenitis Suppurativa. Here are some medications that can be used to treat HS:

Table 1: Medications used to treat Hidradenitis Suppurativa12,13

Treatment

Examples

How Is It Used?

How Does it Work?

Antibiotics

Amoxicillin, Clindamycin, Moxifloxacin

Topical or Oral

Reduces inflammation

Keratolytics

Resorcinol

Topical

Removes superficial skin cells to prevent clogging of follicles

Anti-androgens

Oral contraceptive pills, spironolactone, metformin

Oral

Reduces androgen levels

Corticosteroids

Corticosteroids

Oral or Injectable

Corticosteroid that reduces inflammation

Retinoid

Isotretinoin, Acitretin

Oral

Regulate skin cell turnover

Biologics

Adalimumab (Humira)

Ustekinumab (Stelara)

Infliximab (Remicade)

Anakinra (Kineret)

Injection or IV infusion

Antibodies that attack pro-inflammatory molecules in your body to reduce inflammation

 

For severe HS, surgery is also an option. There are many different types of surgery that can be performed for HS. “Wide excisions” are performed most often to remove affected tissue. Although surgery has helped many people who suffer from HS, it is not always curative. A meta-analysis of the literature found the recurrence rate to be 13.0% following wide excisions of the affected site.14 If you suffer from severe HS, talk to your physician to see if you might benefit from surgery.

What Factors Can Your Patient Control?

Weight

Obesity is a major factor that contributes to disease development and severity.15,16 Those with higher BMIs tend to have more severe disease than those with lower BMIs and weight loss has been shown to alleviate disease.17,18 This could be due to changes in hormones and/or friction in disease-prone areas.11

Smoking

Smoking is another factor strongly correlated with hidradenitis suppurativa. It is a known trigger of the disease, and also believed to increase disease severity.19 Smoking cessation may even improve disease outcome, and must be seriously considered in order to successfully treat the condition.18

Diet

Dairy products and high glycemic index foods can cause insulin spikes, and may worsen symptoms.3,20 Further research is needed to determine a link between diet and HS. However, removing these products from your patient’s diet may improve symptoms, and could be worth a try.

* This Website is for general skin beauty, wellness, and health information only. This Website is not to be used as a substitute for medical advice, diagnosis or treatment of any health condition or problem. The information provided on this Website should never be used to disregard, delay, or refuse treatment or advice from a physician or a qualified health provider.

References

  1. Patel ZS, Hoffman LK, Buse DC, et al. Pain, Psychological Comorbidities, Disability, and Impaired Qualify of Life in Hidradenitis Suppurativa. Curr Pain Headache Rep. 2017;21(12):49.
  2. Pink A, Anzengruber F, Navarini AA. Acne and hidradenitis suppurativa. Br J Dermatol. 2018.
  3. Vekic DA, Frew J, Cains GD. Hidradenitis suppurativa, a review of pathogenesis, associations and management. Part 1. Australas J Dermatol. 2018.
  4. Deckers IE, van der Zee HH, Boer J, Prens EP. Correlation of early-onset hidradenitis suppurativa with stronger genetic susceptibility and more widespread involvement. J Am Acad Dermatol. 2015;72(3):485-488.
  5. Gao M, Wang PG, Cui Y, et al. Inversa acne (hidradenitis suppurativa): a case report and identification of the locus at chromosome 1p21.1-1q25.3. J Invest Dermatol. 2006;126(6):1302-1306.
  6. Ratnamala U, Jhala D, Jain NK, et al. Expanding the spectrum of gamma-secretase gene mutation-associated phenotypes: two novel mutations segregating with familial hidradenitis suppurativa (acne inversa) and acne conglobata. Exp Dermatol. 2016;25(4):314-316.
  7. Savva A, Kanni T, Damoraki G, et al. Impact of Toll-like receptor-4 and tumour necrosis factor gene polymorphisms in patients with hidradenitis suppurativa. Br J Dermatol. 2013;168(2):311-317.
  8. Giatrakos S, Huse K, Kanni T, et al. Haplotypes of IL-12Rbeta1 impact on the clinical phenotype of hidradenitis suppurativa. Cytokine. 2013;62(2):297-301.
  9. Kraft JN, Searles GE. Hidradenitis suppurativa in 64 female patients: retrospective study comparing oral antibiotics and antiandrogen therapy. J Cutan Med Surg. 2007;11(4):125-131.
  10. Lee A, Fischer G. A case series of 20 women with hidradenitis suppurativa treated with spironolactone. Australas J Dermatol. 2015;56(3):192-196.
  11. Khandalavala BN, Do MV. Finasteride in Hidradenitis Suppurativa: A "Male" Therapy for a Predominantly "Female" Disease. J Clin Aesthet Dermatol. 2016;9(6):44-50.
  12. Hogan DJ, Light MJ. Successful treatment of hidradenitis suppurativa with acitretin. J Am Acad Dermatol. 1988;19(2 Pt 1):355-356.
  13. Patil S, Apurwa A, Nadkarni N, Agarwal S, Chaudhari P, Gautam M. Hidradenitis Suppurativa: Inside and Out. Indian J Dermatol. 2018;63(2):91-98.
  14. Mehdizadeh A, Hazen PG, Bechara FG, et al. Recurrence of hidradenitis suppurativa after surgical management: A systematic review and meta-analysis. J Am Acad Dermatol. 2015;73(5 Suppl 1):S70-77.
  15. Canoui-Poitrine F, Revuz JE, Wolkenstein P, et al. Clinical characteristics of a series of 302 French patients with hidradenitis suppurativa, with an analysis of factors associated with disease severity. J Am Acad Dermatol. 2009;61(1):51-57.
  16. Revuz JE, Canoui-Poitrine F, Wolkenstein P, et al. Prevalence and factors associated with hidradenitis suppurativa: results from two case-control studies. J Am Acad Dermatol. 2008;59(4):596-601.
  17. Kromann CB, Deckers IE, Esmann S, Boer J, Prens EP, Jemec GB. Risk factors, clinical course and long-term prognosis in hidradenitis suppurativa: a cross-sectional study. Br J Dermatol. 2014;171(4):819-824.
  18. Sartorius K, Emtestam L, Jemec GB, Lapins J. Objective scoring of hidradenitis suppurativa reflecting the role of tobacco smoking and obesity. Br J Dermatol. 2009;161(4):831-839.
  19. Vazquez BG, Alikhan A, Weaver AL, Wetter DA, Davis MD. Incidence of hidradenitis suppurativa and associated factors: a population-based study of Olmsted County, Minnesota. J Invest Dermatol. 2013;133(1):97-103.
  20. Danby FW. Diet in the prevention of hidradenitis suppurativa (acne inversa). J Am Acad Dermatol. 2015;73(5 Suppl 1):S52-54.
 
 
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