Definition
Hidradenitis suppurativa (HS) is when recurring inflamed nodules (small, solid lump) and cysts (fluid-filled mass) appear in the armpits and groin. These lesions may also be found under the breasts and even around the nipples and anus.
Sweat Gland
The lesions start as plugged pores in the sweat and oil glands. The plugging allows material to build up under the skin. The body's inflammatory system attacks these materials, causing nodules and cysts to form. These lesions can rupture under the skin and form large, painful abscesses; while on the skin's surface, they can form draining sinuses.
The affected areas may have a bad smell and may eventually heal and leave scars. Because HS worsens with time, it is important to treat this condition as early as possible. Having another infection in these lesions is rare, and when it occurs, the bacterium that is almost always present is Staphylococcus aureus—"staph" for short. But, hidradenitis suppurativa is different from true staph infections that cause unrelated conditions such as carbuncles, furuncles, folliculitis, boils, and staph infections of skin glands blocked by acne. Pilonidal cysts may be seen with HS, but may also occur alone.
Causes
Hidradenitis suppurativa is caused when a duct (a channel that carries gland or organ secretions) in the body is blocked. Material traveling in the duct becomes backed up and infected. The sweat and oil glands located in areas where skin folds over on itself, such as the armpits and groin, can become plugged. When this happens, oil, sweat, and dead skin cells build up. Skin bacteria may invade and produce an infection.
Risk Factors
The following factors increase your chance of developing hidradenitis suppurativa. If you have any of these risk factors, tell your doctor:
• Genetics: Although there is little that can be done to treat a genetic disease, it is important to know that this is a major part of the problem. Doctors are still determining what the genetic defect(s) might be.
• Obesity alone or with polycystic ovarian syndrome (PCOS), insulin resistance, or syndrome X
• Androgen dysfunction (excess male hormone)
• Crohn’s disease and other inflammatory autoimmune conditions
• Acne
• Medications: Lithium and some oral contraceptives may make the problem worse.
• Smoking interferes with healing, making the lesions resistant to therapy.
Symptoms
If you experience these symptoms, see your physician soon, before the condition progresses. Symptoms include:
• Painful swellings in the armpits, groin, under the breasts, around the nipples, or around the anus
• Pus leaking from openings in the swellings
• Foul smell from the affected areas
• Scarring
• Depression and social isolation may also occur.
If you experience any of these symptoms due not assume it is due to hidradenitis suppurativa. These symptoms may be caused by other, more or less serious health conditions. If you experience any one of them, see your doctor.
Diagnosis
Your doctor will ask about your symptoms and medical history, and perform a physical exam. This exam should include every crease and fold on your body that might be affected by HS. Tell the doctor about every sore lump you have; some are not visible, but you will know where they are.
Your doctor may refer you to a dermatologist. If the disease is extensive, a dermatological, plastic, general, or gynecological surgeon may be consulted. The important thing is to find a surgeon with experience in treating the abscesses and sinuses.
Tests may include:
• Culture of the drainage to identify the bacteria
Treatment
Talk with your doctor about the best treatment plan for you. Treatment options vary, are not always effective, and include the following:
Hot Packs
Heat is thought to "draw out" an infection, causing drainage to the surface rather than allowing it to spread under the skin. This treatment is uncertain, but repeated warm baths may be used instead of heat packs because they are soothing and may soften the skin surface, allowing abscesses to drain.
Antibiotics
Long-term use of oral and topical anti-inflammatory antibiotics, such as those used in cases of severe acne, may stop inflammation. Be aware that long-term use of antibiotics can gradually produce resistant bacteria and secondary yeast infections.
Cortisone
Cortisone-like drugs, taken orally for a few days, have proven effective for short-term treatment, but should be avoided over the long-term because of slow healing, spreading of infections, and other side effects. These drugs may also be injected into the lesions or applied as a cream or ointment, thus avoiding some of the side effects of the orally administered form.
Male Hormone (Androgen) Suppression
Because the affected glands are in hormone-sensitive areas, managing hormonal abnormality is important. This means using appropriate birth control pills and hormone blockers and not consuming dairy (which contains hormones) for at least a year. The hormone blockers include cyproterone acetate, which is not available in the US, but is used elsewhere either alone or combined with ethinyl estradiol. It can suppress acne in women and has improved hidradenitis suppurativa. Other anti-androgens include drospirenone (available as a birth control pill), flutamide, finasteride, dutasteride, and spironolactone.
Surgery
Individual nodules, cysts, and sinuses can be treated in the doctor's office with "unroofing" procedures. Several visits may be needed to control the numerous areas involved. If the involvement is more severe, then wide excision of the affected area—removing all involved cysts, nodules, and connecting sinuses—might be done as a last resort. The surgical site, if very large, may be covered with a skin graft.
Laser Ablation
Carbon dioxide laser ablation has the same result as surgery.
Biologic Medications
Infliximab and etanercept are the so-called "biologic medications" used to treat a variety of inflammatory conditions. These drugs have recently shown some promise in the treatment of severe cases of HS. These medications, however, must be infused intravenously or injected under the skin, and may be associated with serious adverse events.
Prevention
To help reduce your chances of getting more lesions, take the following steps:
• Don't smoke. If you smoke, quit. Nicotine patches or gum will not block healing the way inhaled smoke can.
• Achieve and maintain a normal body weight.
• There is a possibility that the hormones in milk and other dairy foods may worsen HS, so consider avoiding dairy products. If you also have acne, not consuming dairy products might improve that condition as well.
