Hidradenitis suppurativa is a painful inflammatory skin condition characterized by tender skin nodules that enlarge, coalesce, and drain leaving fibrotic sinus tracts. It is commonly seen in intratiginous regions – the axilla, perineum, inframammary folds, and inguinal folds (areas with abundant apocrine glands). There is an imbalance of wound healing factors, which allows inflammation due to occluded follicles to progress. Diagnosis is clinical. Effective treatment exists, with the most important being lifestyle changes.
Affects 1% of the population. 30% of cases have a strong family history. Affects women more than male (3:1). Mean age of onset is 21 years, and does not occur before puberty.
Hurley classification of Hidradenitis Suppurativa
| Stage | Description |
|---|---|
| Stage I | Single or multiple nodules or abscesses without sinus tracts |
| Stage II | Nodules and abscesses that are associated with sinus tracts and scarring |
| Stage III | Multiple recurrent abscesses and extensive sinus tracts and scar formation |
- Risk factors
- Female
- Genetic predisposition
- Smoking
- Obesity
- Androgen dysfunction
- Metabolic syndrome
- Patient History
- Obesity (60%)
- Acne (50%)
- Hyperlipidaemia (45%)
- Depression (40%)
- Insulin resistance (40%)
- Pilonidal sinus (25%)
- Polycystic ovarian syndrome (15%)
- Type 2 Diabetes Mellitus (15%)
- Hypertension (14%)
- Pyoderma gangrenosum
- Crohn’s disease
- Spondyloarthropathy
- Down’s syndrome
- Pathophysiology
- Follicular occlusion → strong inflammation and cytokine release → abscess formation → worsening of the occlusion
- Abscesses cause follicular rupture → chronic scar and sinus tract formation
- Signs and symptoms
- Deep, painful skin nodules
- In typical distribution (intertriginous areas)
- Lesions are chronic and recurring
- Investigations
- Blood glucose: identifies and associated diabetes or insulin resistance
- Swab MC+S: usually negative
- Supportive treatment
- Lifestyle modifications: smoking cessation, weight loss, wear loose fitting clothes, anti-septic wash (chlorhexidine)
- Pain management with NSAIDs, Paracetamol, or oral steroids
- Assess and treat psychological factors
- Treatment for Hurley Stage I and II
- De-roof the abscess
- Topical agents (chlorhexidine wash)
- Topical antibiotics e.g. Clindamycin 2% cream
- Systemic antibiotics e.g. Doxycycline, Minocycline, and Rifampicin
- Treatment for Hurley Stage II and III
- Wide excision of involved skin (recurrence is common, especially with primary closure rather than grafts and flaps)
- Laser treatments
- Hormonal therapies
- Biologic agents e.g. TNF inhibitors (SC Adalimumab)
- Oral steroids (for managing pain and flares of abscesses)
- Complications
- Scarring → increased risk of Squamous Cell Carcinoma
- Lymphoedema (from obstruction of lymphatic drainage)
- Fistula formation to nearby organs (rare – urethra, bladder, rectum)
- Psychological impact: sexual dysfunction, social isolation, depression (can be managed with referral to Hidradenitis Suppurativa support groups)
- Arthropathy
