Wednesday, July 28, 2010

Hidradenitis Suppurativa

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active.

The July issue of the journal Advances in Skin & Wound Care has a CME review article on the chronic, relapsing skin condition known as hidradenitis suppurativa (HS).  I have given the full article reference below.
When I see patients with this condition, it is because they have already progressed past the first clinical stage into either the second or third stage.  It is due to their family doctor or internist deciding perhaps they are in need of surgery.
HS is not a skin condition anyone wants to have.  Robin in her 365 Project:  365 Days with Cushing’s Disease has discussed living with the condition:
Hidradenitis suppurativa....
I'm lucky.  Mine is "mild" compared to most.  Nonetheless, it's no fun.  In 1985, I saw a doctor because of it.  She told me to use white Dial soap and to lose weight. At that time, I hadn't gained very much weight.   Yes, 25 years ago.  And I'd had other symptoms of Cushing's, also, long before then. 
Hidradenitis suppurativa (hi-drad-uh-NI-tis sup-u-ra-TI-va) is a condition marked by chronic skin inflammation,  occurring in areas that contain apocrine sweat glands, usually the axilla and groin.   The exact cause of hidradenitis suppurativa remains unclear.  According to the article:
HS symptoms were first described in 1839 by Velpeau when a patient presented with superficial abscesses in the axillary, breast, and perianal regions. In 1854, Verneuil associated the condition with the apocrine glands, and the condition was given its current name, although for many years, the process was referred to as Verneuil disease.
Genetics, hormones, endocrine factors, and cigarette smoking have all been reported to play a part in the development of hidradenitis suppurativa (HS).  
The prevalence of HS is approximately 1% to 2% of the general population.  Women are affected by HS three times as often as men.   HS affects all races; but the most severe cases are often seen in people with black skin.
HS can present anytime between puberty and post menopause.  The onset of HS peaks between ages 11 and 50 years.
The extent and severity of the disorder varies widely between individuals. Initially a firm pea-sized nodule (0.5-1.5 cm diameter) resembling acne may appear on one site. These lesions may resolve spontaneously or within hours to days rupture and ooze a pus-like discharge. These may heal without treatment but at a later time new lesions recur in the adjacent area. If uncontrolled, this leads to development of larger lesions (golf ball size), sinus tract formation, and involvement of multiple sites.
Three distinct clinical stages have been defined for the condition.
  • Stage 1 – solitary or multiple, isolated abscess formation without scarring or sinus tracts
  • Stage 2 – recurrent abscesses, single or multiple widely separated lesions, with sinus tract formation
  • Stage 3 – diffuse or broad involvement, with multiple interconnected sinus tracts and abscesses.

Areas that may be affected by HS lesions are the axilla, areola of the breast, submammary fold, periumbilical region, groin, scalp, zygomatic areas of the face, nape of the neck, external auditory meatus, and shoulders.
Treatment, or more accurately management, of HS is difficult. The aim is to catch the disease in its early stages.  Weight loss in obese patients and smoking cessation are recommended.   Other measures include:
  • Good hygiene with ordinary soap. 
  • Wear loose fitting clothing to avoid friction.
  • Topical or oral antibiotics similar to those used for treatment of acne  in higher doses.
Surgical management may include:
  • Incision and drainage of abscesses – at the very painful pointing stage.
  • Persistent hidradenitis lumps may be excised after several months of conservative treatment (i.e. waiting and/or antibiotics).
  • Radical excisional surgery is reserved for very severe cases of hidradenitis suppurativa.
  • Carbon dioxide laser ablation has been proposed as a better alternative to removal of glandular and scar tissue.  The wound is left open to heal by secondary intention. 

Hidradenitis Suppurativa: A Clinician's Tool for Early Diagnosis and Treatment; Beshara, Monica A.; Advances in Skin & Wound Care. 23(7):328-332, July 2010; doi: 10.1097/01.ASW.0000363559.53350.84
Hidradenitis suppurativa – Mayo Clinic
Hidradenitis suppurativa – DermNet NZ  (has photos as well as text information)

1 comment:

cynthia bailey md said...

Retinoids like Accutane can also be helpful because hidradenitis is part of the spectrum of severe cystic acne. Retinoids have to be dosed with care in hidradenitis because there can be a flair of the disease initially; retinoid therapy is best done by a dermatologist or someone with a lot of experience using these medicines with severe acne.
Cynthia Bailey MD,