Hidradenitis Suppurativa

Hidradenitis suppurativa (hidradenitis) is a condition marked by small and often painful lumps under the skin that appear red or darker than one’s natural skin color. People with hidradenitis suppurativa usually notice flare-ups in areas of skin that contain hair follicles, oil glands and sweat glands that react to infection, inflammation and/or swelling. Most often found in the armpits, the groin and the anal area, hidradenitis can also occur in folds of skin where skin rubs together, such as between and below the breasts, between and below the buttocks, and on inner thighs.

Because of the extreme appearance and associated discomfort of hidradenitis suppurativa, people who experience occasional, frequent or chronic flare ups can learn about a variety of treatment options from providers at Mittal Dermatology. Hidradenitis suppurativa is also known as acne inversa, which refers to large acne flare ups that can occur under the skin in an inward or downward direction.

The exact cause of hidradenitis suppurativa is not known definitively. Although smoking and obesity are known to be associated with hidradenitis suppurativa, risk factors include age and gender (most common among women 18-29 years old) and family history.

Your board-certified physician or advanced practitioner at Mittal Dermatology can help you understand what triggers your hidradenitis suppurativa and can inform you of various treatments that range from topical and laser applications to surgery

Many people have never heard of hidradenitis suppurativa

During their first appointment with a dermatologist, patients with hidradenitis suppurativa (HS) often say they have pimples, sores, or lumps on their armpits or groin.

Hidradenitis suppurativa

What is hidradenitis suppurativa?
Hidradenitis suppurativa (HS) is a skin condition that causes painful lumps deep in your skin. These lumps usually develop on parts of the body where skin touches skin like the armpits, inner thighs, and groin area. Dermatologists are the doctors who specialize in the diagnosis and treatment of this condition.

Is HS contagious? No

Many people live with HS for years before getting diagnosed

Also called acne inversa, HS can look like pimples and acne cysts. It’s not acne, though. Still, when HS first appears, some people think that they have pimples in their armpit, on their inner thighs, or in their groin area.

Without treatment for HS, this skin condition can worsen. Abscesses, which are pockets of pus, can develop. When an abscess breaks open, blood and pus leak out. As the abscess heals, a scar usually develops.

You may develop more abscesses in the same area. If the abscesses and scars continue to appear, tunnels can form under the skin. These pus-filled tunnels are called sinus tracts.

Getting medical treatment from a dermatologist before HS worsens can reduce flare-ups and prevent HS from becoming a painful disease that might cause disability.

Because you may not have heard of HS and HS can look like acne, boils, and sores, it can be difficult to know what to do. In fact, when seeing a dermatologist for the first time, many patients describe the reason for their visit as having one or more of the following:

• Armpit pimples or sores

• A lump or cyst in their underarm

• Pimples, cysts, lumps, or boils on their thigh

• Cysts on their groin

If you have any of these signs and have not seen a dermatologist, make an appointment. Dermatologists specialize in diagnosing and treating the skin and can tell you whether you have HS.

Many people live years with HS before being diagnosed. Years of having HS in the groin can cause trouble sitting or walking. Untreated HS in the armpits can make it difficult to reach for things. This happens when scars develop, which can limit how far you can stretch or bend.

People who go undiagnosed for years may live with intense pain. They can develop wounds that are slow to heal or fail to heal.

To get relief from the pain and care for their wounds, they often go to the emergency room (ER). According to a study conducted in Canada, some people return to the ER 10 or more times before getting diagnosed with HS. That’s why it’s important to see a board-certified dermatologist.

Hidradenitis suppurativa is:

● NOT a sexually transmitted disease
● NOT caused by unclean skin
● NOT contagious
● NOT acne

Is HS more common in Black people?

If you live in the United States and are an African American or biracial woman between 30 and 39 years of age, you have a higher risk of developing HS than do other Americans.

Research shows Black people develop this disease more often than people of other races. In a 2017 study, researchers found that for every 100,000 African Americans, 296 had HS.

Other studies have found that HS is more common in women than men. Research shows that at least three times as many women as men develop HS.

Can HS kill you?

HS can be painful. Without treatment, it can cause scars that make it difficult to move. However, HS is rarely life threatening. The only time HS might become life threatening is when someone develops a serious infection. Treatment and self-care for HS can help prevent a life-threatening infection.

Dermatologists are trained to recognize HS

To a dermatologist’s trained eye, there are differences between HS and other conditions like acne and boils. Dermatologists receive the training needed to spot these differences.

With an accurate diagnosis and proper treatment for HS, you can:

• Prevent HS from worsening

• Relieve pain

• Improve wound healing

• Treat an infection, which can develop if you have an open wound

Research has led to many treatment advances in recent years

Breakthroughs in HS research have led to a better understanding of this disease and better treatment for HS.

Today, many patients receive a treatment plan customized to their needs. A treatment plan may include:

• A skin care plan

• Medication

• A procedure that can be performed in your dermatologist’s office, such as draining or removing a painful lump

• Treatment for infection

• Wound care

• Pain control

• Self-care tips

Is there a cure for HS?

HS cannot be cured, but treatment can control the disease. Treatment can prevent new HS and treat existing HS. This means that HS does not have to stop you from living the life you want to live.

Why see a dermatologist?

Dermatologists are the doctors who usually diagnose and treat HS. When you see a dermatologist for HS, your dermatologist will create a treatment plan tailored to your needs and watch your health closely. People with HS have a higher risk for developing some health conditions, including arthritis, diabetes, and heart disease.

For this reason, dermatologists often work closely with other doctors. Doing so helps you get the care you need.

Your dermatologist can also watch for signs of skin cancer on your skin. Some people with HS have a higher risk of developing a common type of skin cancer called squamous cell carcinoma (SCC).

In people who have HS, this skin cancer tends to develop in unexpected places like around the anus or elsewhere in the groin area.

Dermatologists are skin cancer specialists, so they can spot signs of skin cancer early. Caught early, SCC is highly treatable.

Where does hidradenitis suppurativa develop on the body?

You usually get hidradenitis suppurativa (HS) on parts of the body where skin touches skin like in the armpits or inner thighs. The following picture shows where HS is likely to develop.

Hidradenitis suppurativa begins where skin touches skin. If you have a tender, deep lump in any of these areas of your body, see a board-certified dermatologist for a diagnosis. To download this infographic, click on the image.

HS tends to begin in an area with thick, coarse hair like the armpits and groin. As the disease progresses, some people may see HS under their breasts.

HS can also develop in less common locations like near an ear or around the belly button. A few people have developed HS on their face, neck, or back, but this is rare.

What are the signs and symptoms of HS?

If you have this skin disease, you may notice breakouts on your skin that look like pimples or boils. Often, these breakouts clear for a while. Later, you may see new breakouts develop in the same area. Sometimes, the breakouts develop in exactly the same spot.

The following pictures show how HS develops and how it can worsen without treatment:

Area of skin feels uncomfortable

Before you notice a lump in your skin, you may feel some discomfort. The area where the lump will appear may swell. Some people say their skin burns, itches, or sweats excessively.

Tender, deep nodule(s) appears

The first sign of HS is often a painful spot that looks like a deep pimple, acne cyst, or boil. This spot often appears on an armpit (as shown here) or in the groin area. Some people develop a spot on their buttocks or inner thigh.

Nodules grow and start to join together

As HS progresses, you see more lumps that may look like acne or boils. These lumps can grow and join together. As the lumps grow together, they fill up with fluid and become painful. These painful lumps are called abscesses.

Large, painful abscess breaks open

When an abscess breaks open, blood and pus spill out. This foul-smelling mixture can cause wet spots on your clothes. People often feel embarrassed by the odor.

Blackhead-like spots

In the advanced stages, some people see small black bumps that look like blackheads. These spots often appear in twos.

Abscesses heal slowly (if at all) and return; scars form

The repetitive healing and reopening eventually cause tunnels to form beneath the skin, which are called sinus tracts, and permanent scars.

Some people have HS wounds on their skin all the time. For others, scars may be the only sign of HS for a while.

Treatment can prevent HS from progressing

Without treatment, HS can continue to heal and reappear. Sometimes, it worsens. When this happens, HS can progress from a few acne-like breakouts (left) to deeply scarred skin (right).

Living with untreated HS can affect your life in different ways. Some people develop one or more of the following:

Anxiety: If you don’t know what’s happening to your skin and why you keep getting these lumps, you may feel anxious.

Depression: Medical studies have found that people who have HS tend to develop depression more often than people who do not have HS.

Infections: A bacterial infection can develop in skin with HS.

Itch: HS on the groin, armpits, or thighs tends to be itchiest.

Pain: The deep lumps and tunnels that develop beneath the skin can be painful. Some people need prescription-strength painkillers to help manage the pain.

Scars that restrict movement: As the body produces more and more scar tissue, the scars can thicken. Some scars become so thick that they limit how far you can move.

Skin cancer: Some people with HS have an increased risk of developing a type of skin cancer called squamous cell carcinoma (SCC).

This skin cancer tends to develop where you’ve had HS for years. Men who’ve had HS on their genitals or around their anus for many years are most likely to get SCC.

Can HS cause joint pain?

If you have HS, arthritis may be causing your joint pain. In studies, researchers have found that HS increases your risk of developing some types of arthritis.

Joint pain and morning stiffness are common symptoms (what you feel) of arthritis.

Researchers continue to study this connection between HS and joint pain. We know that both cause inflammation. This fact may shed more light on what causes HS.

What causes hidradenitis suppurativa?

The cause of this disease is still a bit of a mystery. Based on what scientists have learned so far, we know that hidradenitis suppurativa (HS) begins in hair follicles. These are tiny structures in our skin from which hair grows.

Here’s what scientists believe happens inside a hair follicle when HS develops:

1. The hair follicle becomes clogged with keratin (a protein found in our skin, hair, and nails).

2. As keratin and sweat (which can no longer flow out of the clogged hair follicle) build up, bacteria breed inside the hair follicle.

3. When a hair follicle has more keratin, sweat, and bacteria than it can hold, the hair follicle bursts. This causes what looks like a deep, painful pimple (nodule) or painful and swollen lump filled with pus (abscess).

4. The material that pours out of the ruptured hair follicle spreads to nearby hair follicles.

5. As more hair follicles become clogged, more lumps form.

6. After the skin heals, it scars. Years of flare-ups can cause thick scars that limit how much you can move.

7. Without treatment, hair follicles may continue to clog and burst open. This can cause tunnels to form deep in the skin. Some people develop serious infections.

In the United States, young women who are African American or biracial are most likely to get hidradenitis suppurativa (HS).

Is HS an autoimmune disease?

While studying HS, researchers have found some evidence that HS might be an autoimmune disease. People with HS develop antibodies. This finding alone doesn’t mean that HS is an autoimmune disease.

The body naturally releases antibodies to destroy bacteria, viruses, and other invaders that shouldn’t be inside the body.

When someone has an autoimmune disease, antibodies mistakenly attack a part of the body. For example, a person develops rheumatoid arthritis when the body attacks its own joints.

To know whether HS is an autoimmune disease, more research is needed to find out why the body is producing antibodies.

Who gets HS?

Some people have a greater risk of developing HS. Here’s what researchers have found can increase your risk of developing HS:

Blood relative with HS: This disease can run in families. Many people who develop HS have a family member with this disease.

While having a blood relative with HS may increase your risk, it’s important to keep in mind that many people who develop this disease do not have a blood relative with HS.

Exposure to a trigger: To get HS, it seems that something must trigger it. Scientists believe that cigarette smoking is the most common trigger for HS. Researchers have found that between 70% and 90% of people who get HS smoke cigarettes.

Being overweight also seems to trigger HS. The more overweight you are, the higher your risk of developing HS and of having severe HS.

What triggers HS for one person may not trigger it for another.

Gender: Females get HS more often than males. It’s still not clear why this happens.

Hormones may play a role. This could explain why HS can flare before you get your period. It would also help explain why HS can be less severe during pregnancy and after menopause begins.

Age: Most people develop HS between puberty and before 40 years of age. It’s very rare for HS to begin before puberty.

Race: In the United States, African Americans, Hispanics, and people who are biracial develop HS more often than white people.

Studies find that African Americans tend to have more severe HS. African Americans who have HS also tend to have a greater risk of developing a type of skin cancer called squamous cell carcinoma. This skin cancer can develop where you’ve had HS for many years.

Psoriasis: If you have psoriasis, a condition that causes scaly patches on the skin, you have a higher risk of developing HS.

While what causes HS is still a mystery, these findings have given us a better understanding of what causes HS and also led to better ways to treat this condition. Today, treatment often requires a multi-pronged approach that includes medication, skin care, and self-care.

A dermatologist is often the doctor who diagnoses a patient with hidradenitis suppurativa (HS)

Getting an accurate diagnosis and an individualized treatment plan can prevent HS from worsening.

How do dermatologists diagnose hidradenitis suppurativa?

Hidradenitis suppurativa (HS) can look like another skin condition, such as worsening acne, boils, or herpes. Dermatologists have the training needed to spot the differences between HS and other conditions. This unique training allows them to diagnose HS more quickly.

If your dermatologist suspects that you may have HS, here’s what typically happens. Your dermatologist will:

• Ask where you have lumps, draining, and other signs of HS. HS tends to occur in certain areas.

• Examine some (or all of) the bumps and sores. HS has certain features, which to the trained eye, distinguish it from acne, boils, or other conditions.

• Talk with you about what they see on your skin. Asking about your symptoms, when the bumps appear, and other specifics helps your dermatologist give you an accurate diagnosis.

If you have a sore or wound that is leaking fluid, your dermatologist may swab a bit of the fluid onto a slide and test it. This can tell your dermatologist whether you have an infection.

That’s usually all that’s needed for a dermatologist to diagnose HS. If you have HS, your dermatologist will create a treatment plan tailored to your needs.

How do dermatologists treat HS?

Although HS cannot be cured, your dermatologist can create a treatment plan to control the disease and lessen your symptoms. Treatment can:

• Reduce flare-ups

• Heal wounds

• Relieve pain

• Prevent HS from worsening

When creating a treatment plan, your dermatologist will consider the types of lesions you have, whether you have pain or an infection, and how HS is affecting your life. This allows your dermatologist to customize a treatment plan for you.

A treatment plan for HS can have many parts and may include one or more of the following:

• A skin care plan

• Medication, an in-office procedure, or both

• Treatment for infection

• Wound care

• Pain control

Here’s what each involves:

Skin care: Some soaps and other skin care products may irritate skin with HS. To reduce this irritation, your dermatologist can create a skin care plan for you. This plan may include using a wash with benzoyl peroxide and switching to a gentle antiperspirant.

Medication to treat HS: Many medications are used to treat HS. Some you apply to the HS. If you have advanced HS, you may need a medication that works throughout the body, such as a pill.

Medications that you apply to the HS include:

• An antibiotic, such as clindamycin or dapsone, to reduce pus-filled lumps and treat infection

• Resorcinol, a peel that opens up clogged hair follicles and reduces inflammation

When stronger medication is necessary, your dermatologist may prescribe:

• An antibiotic (Some patients receive a combination of antibiotics.)

• Acitretin, a retinoid that you take by mouth

• Hormonal medication, such as birth control pills, spironolactone, or finasteride

• Metformin, a diabetes drug, which can reduce inflammation

• A biologic, which works on the immune system to stop the pus and inflammation

While many medications are used to treat HS, the U.S. Food and Drug Administration (FDA) has approved only one. It’s a biologic called adalimumab (ad-ah-lim-you-mab).

The FDA approved adalimumab in 2015. In studies that led to its approval, the patients who received adalimumab had noticeably fewer abscesses (lumps with pus) and nodules (hard, deep lumps) than the patients who did not receive the biologic.

The FDA has approved adalimumab for people 12 years of age or older who have moderate or severe HS.

Adalimumab is a strong medication, so it’s not necessary for every patient.

In-office procedure for HS: Some patients can benefit from a treatment plan that uses both medication and an in-office procedure. In-office procedures are especially important if HS has made tunnels in your skin.

Procedures that dermatologists use to treat HS include:

• Corticosteroid injection: When injected into an HS lesion, this medication can reduce inflammation. Dermatologists use this procedure to treat early painful nodules that are not infected. It cannot treat tunnels under your skin.

• Laser hair reduction: Reducing the amount of hair on the skin with HS can reduce the number of HS lumps that you have. Your dermatologist will tell you how many treatments you’ll likely need. Treatment is given once every four to six weeks. It takes about one month to notice an improvement.

• Botulinum toxin: While most people think of this medication as a treatment for wrinkles, the FDA has also approved this medication to treat excessive sweating. Your dermatologist may recommend botulinum toxin to reduce sweating, which can reduce infections.

• Incision and drainage: Used to drain a painful HS abscess (pus-filled lump), this procedure can relieve the pain and pressure quickly. However, most abscesses return.

• Deroofing: This procedure is called deroofing because your dermatologist removes the skin covering the top of a sinus tract or abscess. The wound caused by removing this skin is left open so that it can heal on its own. Leaving an open wound reduces the likelihood that the HS lesion will return. This is an option for people whose HS repeatedly returns to the same location.

• Wide excision: During this procedure, a dermatologist removes an HS lesion, such as a tunnel beneath the skin. This may be an option if medication fails to help. As in deroofing, the wound caused by wide excision is left to heal on its own. Most patients have a long, wide, and open wound after this procedure.

• Laser surgery: Strong lasers can vaporize HS. Before performing this laser surgery, your dermatologist will use medication to get the HS under control. To be effective, the HS must remain the same for weeks before you have laser surgery. After surgery, it may take up to 6 months for your skin to heal.

Wound care: This plays an important role in treating HS, as the disease can cause slow-healing or non-healing wounds. If you need wound care, you will learn how to do this at home. In the beginning, some patients need to change their dressings several times a day.

What you use to care for your wounds can vary. Your dermatologist will consider where you have wounds, the amount of leakage coming from the wounds, what the skin around each wound looks like, cost, and your preferences.

Along with dressing changes, your dermatologist may recommend the following:

• To decrease the odor: Soak a clean washcloth in diluted white vinegar and apply before you dress a wound.

• To relieve the pain and discomfort: Use an antiseptic wash.

If a wound fails to heal, hyperbaric oxygen therapy (HBOT) may be an option. HBOT is better known for treating scuba divers who come up from a dive too quickly. Patients receive HBOT by going into a special chamber. The oxygen level inside the chamber is higher than the normal oxygen level. Getting more oxygen into your blood may help heal non-healing wounds.

Pain control: Pain is a common symptom of HS. To help you manage your pain, your dermatologist may recommend:

• Treatment you apply to your skin: Ice packs and lidocaine can be effective for mild pain. For more intense pain, your dermatologist may prescribe a medication made by a compounding pharmacy.

• Medication you take: A pain relief medication that you can buy without a prescription is commonly used to treat mild pain. If you need stronger medication, your dermatologist may prescribe a medication or refer you to a pain specialist.

• Complementary and alternative medicine (CAM): Options include acupuncture and medical marijuana.

While medication can help control pain short-term, research shows that the best way to control pain is to treat the HS.

Depression or anxiety: If HS has caused you to develop depression or anxiety, your dermatologist may recommend psychological counseling. Many patients find that counseling, along with joining an HS support group, helps them a great deal.

To get the best outcome from treatment, dermatologists recommend self-care.

Patients often ask their dermatologist if they should squeeze hidradenitis suppurativa (HS)

The answer is “no.” Squeezing or popping the nodules, cysts, and sores can injure or irritate your skin. Anything that injures or irritates your skin can worsen HS.

To help their patients who have hidradenitis suppurativa (HS) get the best results from treatment, here’s what dermatologists recommend you do at home:

1. Wash your skin with an antimicrobial wash. This helps reduce bacteria on your skin. When there's less bacteria, you may have fewer flare-ups.
   
   One product that can decrease the bacteria on your skin is an acne wash that contains benzoyl peroxide or zinc pyrithione.

2. Quit scrubbing your skin. Patients often think that having HS means they have dirty skin. You don’t have dirty skin. If you’re scrubbing your skin to get it clean, stop. Scrubbing causes inflammation, which can worsen HS.

3. Take care when shaving or waxing skin with HS. In general, dermatologists recommend that patients with HS never wax. Waxing can irritate the skin, which may cause more HS.
   
   If you shave, take extra precautions to avoid nicks and cuts, which could cause a new HS sore or an infection. Here are the precautions that dermatologists recommend:

   • Before you shave, wash the area with an antibacterial soap.

   • Soften and protect your skin by applying a gel-to-foam shaving gel.

   • Shave carefully.

4. Consider laser hair removal as a way to remove hair where you have HS. Studies have shown that getting laser hair removal can reduce flare-ups of HS. Laser treatment can be effective because it reduces the number of hair follicles you have, decreases bacteria on your skin, and makes sebaceous glands less active.
   
   While laser hair removal may sound appealing, it’s important to know that it can be costly. Insurance doesn’t cover the cost, so you’ll need to pay for this treatment.
   
   If you and your dermatologist decide that laser hair removal is right for you, you’d see a dermatologist who performs this procedure. Dermatologists perform laser hair removal during an office visit. The dermatologist who performs the laser hair removal can tell you how many sessions you’ll need. Sessions are generally spaced about 6 weeks apart. It can take time to get the desired results.

5. Treat a painful lump at home with heat. To use heat on HS, dermatologists recommend one of the following methods:

   • Black tea compress: To make this compress, place a teabag of black tea in a cup. Pour boiling water over the teabag, and let it seep for 10 minutes until the water is warm rather than hot.
     
     Place a clean, soft cloth or gauze into a clean container and pour the tea over the cloth or gauze. You now have a black tea compress. Wring out the excess liquid and place the compress on the painful HS.
     
     Keep the compress on the HS for 10 minutes. Repeat several times a day as needed to reduce the pain.

   • Warm water compress: To make this compress, place a clean washcloth under warm running water. Wring out the excess water and place the washcloth on the painful lump. Leave the washcloth on the area for 10 minutes.
     
     You can repeat this several times during the day to reduce pain. This warm compress can also help drain painful HS.

6. Avoid sweating and overheating. While applying heat to a painful lump can bring relief, sweating and overheating tend to worsen HS. To reduce sweating, dermatologists recommend that you:

   • Limit your activity when you’re in a warm or hot place, including the outdoors.

   • Stay in a cool indoor space. If that’s not possible, cool down in an air-conditioned place whenever possible.

   • In warm weather, try to be outdoors in the morning or late afternoon when it’s cooler.

   If your work or the area where you live make it difficult to avoid sweating or overheating, ask your dermatologist to give you individualized advice.

7. Use a mild and effective antiperspirant or deodorant. Some products are too harsh for skin with HS. Look for an antiperspirant or deodorant that does NOT contain alcohol, baking soda, parabens, dyes, or fragrance. These ingredients can irritate the skin and cause HS to flare.

   An effective antiperspirant or deodorant can prevent worsening HS in the underarm area

   If cannot find an antiperspirant or deodorant that keeps you dry without irritating your skin, ask your dermatologist to recommend one.

8. If you have a wound-care treatment plan, follow it. If HS has caused wounds, your dermatologist will create a treatment plan to help heal wounds and prevent infection.
   
   Wounds can be difficult to treat. Tell your dermatologist if any wound fails to heal, opens up after healing, or becomes more painful.

9. Wear looser clothing if your HS flares when you wear tight or form-fitting clothes. When clothing rubs on skin with HS, it can irritate your skin, causing HS to worsen. If you need to wear tight-fitting athletic clothing or leggings, ask your dermatologist for advice on how to reduce flare-ups.

10. Tell your dermatologist if you have joint pain. People living with HS have a higher risk of developing diseases that affect the joints like arthritis.

    Lifestyle changes can have long-lasting effects

    Patients who quit smoking or lose extra weight can have fewer HS flare-ups (and sometimes get rid of) hidradenitis suppurativa.

11. If you are overweight, lose weight. For many patients who are overweight and have HS, losing weight can reduce flare-ups and prevent HS from worsening. In some studies, patients who lost weight saw their HS go away.
    
    Losing weight has additional benefits for anyone who has HS. Studies show that people with HS have a higher risk of developing heart disease and diabetes. Losing weight and eating a healthy, well-balanced diet can reduce your risk of developing these and other diseases.
    
    If you’re having trouble losing weight, ask your dermatologist or primary care doctor about programs that can help you.

12. If you smoke, stop smoking. Quitting smoking can help you live a longer, healthier life. It can also reduce HS flare-ups and prevent HS from worsening.
    
    Occasionally, patients who stop smoking get rid of their HS.
    
    For many people, quitting smoking is difficult. The cravings for nicotine can be intense. To help people quit, the American Lung Association (ALA) has been offering a quit smoking program for more than 35 years. Today, the ALA says that it’s ranked as one of the most effective programs for helping people quit smoking for good.