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BASICS

Description

  • Chronic inflammatory skin disease with recurrent nodules, abscesses, sinus tracts, complex scarring.
  • Lesions tender, malodorous, often exudative.
  • Common sites: axillae, groin, perianal, perineal, inframammary.
  • Also impacts psychosocial health.

Epidemiology

  • Female > male (3:1).
  • More common in African Americans.
  • Peak onset: 2nd-3rd decades; range puberty to 40 years.
  • Prevalence: 1-4%.

Etiology and Pathophysiology

  • Likely follicular epithelium defect, not purely apocrine gland disorder.
  • Hormonally driven keratinocyte proliferation → follicular occlusion.
  • Mechanical stress → follicular rupture → immune response.
  • Secondary bacterial infection.
  • Sinus tracts from rupture and reepithelialization.
  • Genetics: familial cases suggest autosomal dominant or polygenic.
  • ~40% have family history.

Risk Factors

  • Obesity
  • Smoking
  • Hyperandrogenism
  • Lithium use may trigger/exacerbate

General Prevention

  • Weight loss
  • Smoking cessation
  • Avoid tight/synthetic clothes, friction, heat, sweating, shaving, deodorants
  • Use antiseptic soaps

Commonly Associated Conditions

  • Acne vulgaris, acne conglobate
  • Dissecting cellulitis of scalp
  • Pilonidal disease
  • Metabolic syndrome/obesity
  • PCOS, androgen dysfunction
  • Thyroid disease
  • Seronegative arthritis/spondyloarthritis
  • IBD
  • Squamous cell carcinoma (risk in chronic HS)
  • PAPASH syndrome
  • Type 2 diabetes mellitus

DIAGNOSIS

History

  • Diagnostic criteria (2nd Int. Conference 2009): morphology, location, chronicity.
  • Lesions: painful nodules, abscesses, draining sinus tracts, bridged scars, “tombstone” pseudocomedones.
  • Location: axillae, groin, perianal/perineal, buttocks, infra/intermammary folds.
  • Chronic relapsing course, often refractory.

Physical Exam

  • Tender dome-shaped nodules 0.5–3.0 cm.
  • Lesions correspond with apocrine-related areas.
  • Hurley staging:
  • I: Nodules/abscesses without sinus tracts/scarring
  • II: Multiple lesions with widely spaced tracts/scars
  • III: Diffuse, interconnected tracts/abscesses/scarring
  • Sartorius scoring and other tools assess severity and treatment response.
  • Lesions often fluctuant with possible malodorous discharge.

Differential Diagnosis

  • Acne vulgaris/conglobate
  • Furunculosis/carbuncles
  • Bartholin/sebaceous cyst infections
  • Lymphadenopathy/lymphadenitis
  • Langerhans cell histiocytosis
  • Actinomycosis
  • Granuloma inguinale
  • Lymphogranuloma venereum
  • Apocrine nevus
  • Crohn disease with fistulae
  • Fox-Fordyce disease

Diagnostic Tests

  • Cultures often negative; if positive, polymicrobial (S. aureus, S. epidermidis)
  • Labs: ESR, leukocytosis, anemia, iron studies, serum electrophoresis changes.
  • Biopsy for SCC suspicion.
  • Hormonal evaluation if female with obesity/hirsutism.
  • Ultrasound for sinus tract extent.

TREATMENT

General Measures

  • Education, psychosocial support.
  • Hygiene: gentle cleansing, avoid shearing stress.
  • Avoid dairy, high glycemic load diet.
  • Smoking cessation and weight loss essential.
  • Symptomatic pain control.
  • Warm compresses, sitz baths, topical antiseptics.

Medications

First Line

  • Stage I: topical/systemic antibiotics; chlorhexidine cleansers.
  • Topical clindamycin 0.1% BID for 12 weeks.
  • Systemic tetracyclines (e.g., doxycycline 100 mg BID) for 12 weeks.
  • Dapsone 50-150 mg daily (less effective in Hurley III).
  • Intralesional corticosteroids (triamcinolone acetonide 10 mg/mL).
  • Stage II/III: consider early dermatology referral.
  • Biologics: Adalimumab 40 mg weekly approved; TNF-α inhibitors improve severity/quality of life.

Second Line

  • Clindamycin + rifampin combination.
  • Hormonal agents (mixed evidence).
  • Retinoids (second/third line).
  • Immunosuppressants (methotrexate, azathioprine, colchicine, cyclosporine).
  • Short/long-term corticosteroids.
  • IV ertapenem (6 weeks) as bridge to surgery (resistance and cost limits).

Surgery

  • Indicated for tunnel/scar removal, refractory disease.
  • Wide excision preferred for cure.
  • Laser therapy, cryotherapy, photodynamic therapy not routinely recommended.

ONGOING CARE

  • Monthly follow-up for symptom and treatment evaluation.
  • Diet: avoid dairy and high glycemic foods.
  • Zinc supplementation may help.

PATIENT EDUCATION

  • Chronic, relapsing disease with variable severity.
  • Medications are mostly temporizing.
  • Surgery offers best chance for cure in severe disease.
  • Smoking cessation and weight loss improve outcomes.
  • Psychosocial impact significant.

PROGNOSIS

  • Lesions heal slowly (10-30 days).
  • Recurrences over years.
  • Severe disease causes progressive scarring and sinus tracts.
  • Radical wide excision best chance for cure.
  • Increased all-cause mortality.

COMPLICATIONS

  • Skin contracture and stricturing.
  • Lymphatic obstruction, lymphedema.
  • Psychosocial: anxiety, depression, self-injury.
  • Anemia, amyloidosis, hypoproteinemia.
  • Epidural abscess, sacral osteomyelitis.
  • Squamous cell carcinoma in chronic tracts.
  • Disseminated infection or sepsis (rare).
  • Urethral, rectal, bladder fistulas (rare).

REFERENCES

  1. Seyed Jafari SM, Hunger RE, Schlapbach C. Hidradenitis suppurativa: current understanding of pathogenic mechanisms and suggestion for treatment algorithm. Front Med (Lausanne). 2020;7:68.

  2. Saunte DML, Jemec GBE. Hidradenitis suppurativa: advances in diagnosis and treatment. JAMA. 2017;318(20):2019-2032.

  3. Lim SYD, Oon HH. Systematic review of immunomodulatory therapies for hidradenitis suppurativa. Biologics. 2019;13:53-78.

  4. Alikhan A, Lynch PJ, Eisen DB. Hidradenitis suppurativa: a comprehensive review. J Am Acad Dermatol. 2009;60(4):539-563.

  5. Wang SC, Wang SC, Sibbald RG. Hidradenitis suppurativa: a frequently missed diagnosis, part 1: a review of pathogenesis, associations, and clinical features. Adv Skin Wound Care. 2015;28(7):325-334.

Additional Reading: - Jemec GBE. Clinical practice. Hidradenitis suppurativa. N Engl J Med. 2012;366(2):158-164.