Hidradenitis Suppurativa (HS) (Acne inversa)

What is hidradenitis suppurativa (acne inversa)?

Hidradenitis suppurativa (HS), also known as acne inversa, is a chronic skin condition characterised by recurrent painful nodules and abscesses in the skin folds. These areas most commonly include the underarms and groin, but HS can also affect the buttocks, under the breasts, back of the neck, and behind the ears.

Unlike acne vulgaris, HS is a distinct condition with unique symptoms and treatment approaches. While both conditions involve skin lesions, the nature, location, and management of these lesions differ significantly between HS and acne vulgaris.

There are three stages of hidradenitis suppurativa:

• Stage 1: this is a mild disease characterised by isolated single or multiple abscesses. These abscesses typically do not cause scarring.
• Stage 2: moderate disease comprises recurrent abscesses with the formation of sinus tracts — narrow tunnels that form under the skin, connecting different abscesses. Scarring is present but limited compared to stage 3 hidradenitis suppurativa.
• Stage 3: advanced disease is characterised by the widespread involvement of interconnected sinus tracts and abscesses. Individuals with stage 3 hidradenitis suppurativa experience significant scarring, often leading to morbidity and debilitating complications.

What causes hidradenitis suppurative?

The exact cause of HS is not fully understood, but it is believed to involve a combination of factors, including:

• Blocked hair follicles: HS may start with blocked hair follicles, leading to inflammation and infection.
• Immune system dysfunction: evidence suggests that HS involves an abnormal immune response, where the body's immune system mistakenly attacks hair follicles and sweat glands, leading to inflammation and the formation of abscesses.
• Hormonal factors: hormonal changes, such as those occurring after childbirth or hormonal fluxes during periods, may trigger or worsen HS symptoms.

What are the symptoms of hidradenitis suppurativa?

Common symptoms of hidradenitis suppurativa include:

• Tender nodules: small, painful lumps that form under the skin.
• Painful abscesses: larger, deeply inflamed lesions that are often very painful.
• Malodorous discharge: when abscesses rupture, they can release a foul-smelling, purulent discharge.
• Sinus tracts: interconnected tunnels form under the skin over time, leading to further complications and scarring.

Commonly affected areas include:

• Armpits
• Groin folds
• Under the breasts (inframammary folds)
• Between the buttocks (natal cleft)
• Behind the ears
• Nape of the neck
• Waist, trunk, and other areas of the body (in advanced or stage 3 hidradenitis suppurativa)

Conditions associated with hidradenitis suppurativa: hidradenitis suppurativa is also associated with obesity, metabolic syndrome, and inflammatory bowel disease.

At Lumine Dermatology & Laser Clinic, we understand the physical and emotional impact hidradenitis suppurativa can have on our patients. We are dedicated to providing expert care, from accurate diagnosis to personalised treatment plans, including medical and surgical options to manage symptoms and improve quality of life. If you are experiencing symptoms of HS, we encourage you to reach out for a consultation so we can help you on your path to recovery.

Who is at risk of hidradenitis suppurativa?

The risk factors for hidradenitis suppurativa include:

• Genetics: 40% of those who suffer from hidradenitis suppurativa have a family member affected by the same condition.
• Medical conditions: individuals with certain medical conditions, such as diabetes, inflammatory bowel disease (IBD), arthritis, and metabolic syndrome, may be more likely to develop hidradenitis suppurativa.
• Hormonal: some individuals have perimenstrual flares of the condition with an improvement of symptoms during pregnancy.
• Smoking: smoking is significantly correlated with an elevated risk of hidradenitis suppurativa.
• Diet: high glycemic index foods and dairy products can exacerbate hidradenitis suppurativa.

How is hidradenitis suppurativa diagnosed?

It can be challenging to receive a correct diagnosis of hidradenitis suppurativa, especially in the early stages, as it is sometimes mistaken for folliculitis or recurrent furunculosis.

Hidradenitis suppurativa is a clinical diagnosis, and we typically look for characteristic lesions in the typical distribution of hidradenitis suppurativa. A history of recurrent and persistent lesions (at least two episodes in six months) is also helpful. Occasionally, we perform biopsies to exclude atypical infections that can mimic hidradenitis suppurativa.

It is best to consult with a dermatologist who can provide specialised treatment and a precise diagnosis of this condition based on the severity of symptoms, medical history, and a visual examination.

What are the treatment options for hidradenitis suppurativa?

Over the years, Dr Evelyn at Lumine Dermatology & Laser Clinic has helped many patients with hidradenitis suppurativa who have had the disease significantly affect all aspects of their lives.

At our clinic, we believe it does not have to be this way. However, early intervention is essential for hidradenitis suppurativa to minimise progressive scarring, which can affect treatment response. Managing hidradenitis suppurativa requires expertise and a multifaceted approach, often combining surgical and medical approaches with the occasional use of energy-based devices.

Medical approaches to treating hidradenitis suppurativa

• Topicals: we use topical antibiotics, antiseptics, steroids, saline compresses, and antiseptic washes to control the condition and alleviate symptoms.
• Oral antibiotics: we prescribe doxycycline, erythromycin, and clindamycin to combat infection and inflammation.
• Oral spironolactone (for females): oral spironolactone isan effective treatment for female patients, helping manage HS's hormone-related aspects.
• Oral immunosuppressants: oral immunosuppressants may be recommended for acute flares or long-term control of HS.
• Biologics: advanced treatments like adalimumab and ustekinumab are available to target inflammation at its source, offering relief for many patients.

Surgical approaches to treating hidradenitis suppurativa

• Incision and drainage: this procedure can alleviate discomfort significantly and provide immediate relief from acute abscesses.
• Deroofing: a targeted approach for persistent abscesses or nodules, offering considerable success in reducing symptoms.
• Excision of nodules and fibrous tracts: for severe cases, removing nodules and fibrous tracts can provide a lasting solution and significant relief.

Frequently asked questions

What triggers acne inversa or hidradenitis suppurativa (HS)?

Although the cause of hidradenitis suppurativa is not fully understood, it is believed to involve a combination of genetic, environmental, and hormonal factors. Factors such as obesity, smoking, and metabolic syndrome may be associated with an increased risk of developing this condition.

Does acne inversa or hidradenitis suppurativa (HS) go away on its own?

There is no cure for HS, but various treatment methods can manage this condition well. Your dermatologist can advise you further on managing this painful and chronic skin condition.

What happens if acne inversa or hidradenitis suppurativa (HS) is left untreated?

If left untreated, HS can lead to complications such as infections. With each flare-up, there will be more scarring, rendering some topical and oral treatments less effective and the condition more complicated to manage. Moreover, the psychological impact of living with a chronic, often painful skin condition can lead to depression, anxiety, and social isolation. It is best to seek treatment as early intervention is critical to managing and treating HS.