Hidradenitis Suppurativa (HS), also known as acne inversa, is a chronic, debilitating inflammatory skin disorder that significantly impacts the quality of life for those affected. It is a condition characterized by recurrent, painful, deep-seated nodules, abscesses, and draining tunnels that typically develop in intertriginous areas—where skin rubs together—rich in apocrine glands. These areas commonly include the axillae, groin, perianal and perineal regions, buttocks, and inframammary folds.
What Exactly is Hidradenitis Suppurativa?
Hidradenitis Suppurativa is a chronic skin disease primarily affecting the hair follicles in specific areas of the body. The initial lesions manifest as painful, deep-seated nodules that may resemble boils or large pimples. As the disease progresses, these nodules may rupture and discharge purulent material. The chronic, unrelenting cycle of inflammation, rupture, and healing often results in the formation of sinus tracts—epithelial-lined tunnels beneath the skin—and leads to irreversible fibrosis and contractures.
HS can be categorized into three stages based on the Hurley Staging System: Stage I (mild, isolated nodules without sinus tracts or scarring), Stage II (moderate, recurrent abscesses with limited sinus tracts and scarring), and Stage III (severe, diffuse or almost diffuse involvement with extensive interconnected sinus tracts and abscesses across an entire anatomical area).
Why Does Hidradenitis Suppurativa Occur?
The exact etiology of Hidradenitis Suppurativa is still not fully elucidated, but it is widely accepted as a complex, multifactorial disease driven by a combination of genetic, environmental, and immunological factors. It is fundamentally considered an autoinflammatory syndrome, meaning the immune system appears to malfunction and trigger inflammation without an external infection.
The primary event in pathogenesis is follicular occlusion, likely caused by abnormal keratinization (keratin plugging) and hyperplasia of the follicular epithelium. This blockage causes keratin and cellular debris to accumulate. The hair follicle eventually distends and ruptures, releasing its contents—including follicular material and commensal bacteria (normal skin flora)—into the surrounding dermis. This release triggers a massive, dysregulated innate immune response, leading to the characteristic deep, painful inflammation and abscess formation.
What are the Major Risk Factors for Developing HS?
Several factors have been strongly implicated in increasing the risk of developing or worsening HS:
Genetics: Approximately 30% to 40% of HS patients report a family history of the condition, suggesting an inherited genetic predisposition.
Smoking: Cigarette smoking is one of the most significant environmental risk factors, associated with both increased risk and greater disease severity. Nicotine and other components may contribute to follicular occlusion.
Sex and Age: HS typically emerges after puberty, suggesting a hormonal influence. Women are generally affected more often than men in North America and Europe, although this ratio can vary globally.
It is crucial to emphasize that HS is not contagious and is not caused by poor personal hygiene.
How is Hidradenitis Suppurativa Diagnosed?
• Typical Lesions: The presence of characteristic lesions, which include deep-seated, painful nodules, abscesses, draining sinus tracts, and/or bidouble comedones.
• Typical Anatomical Predilection: The lesions must be located in specific, apocrine-gland-rich areas, such as the axillae, groin, perineal/perianal regions, or inframammary folds.
• Chronicity and Recurrence: The disease course must be chronic and recurrent, typically defined as having had at least two episodes in the last six months.
Can a Dermatoscope Detect Hidradenitis Suppurativa?
A dermatoscope can be useful in the detection and characterization of Hidradenitis Suppurativa (HS), especially in its early or milder forms, by enhancing the visualization of specific structural features that may be missed by the naked eye. While the diagnosis of HS remains primarily clinical, based on the characteristic lesions, location, and recurrence, dermoscopy provides a non-invasive tool to support diagnostic accuracy and differentiate HS from other skin conditions like simple boils or folliculitis.
Dermatoscopy may help clinicians observe surface clues that support the diagnosis, such as:
• Dilated pores
• Double-ended pseudocomedones: This is considered one of the most characteristic dermoscopic findings of HS. They typically contain black or dark brown keratin accumulations at each end, often embedded within a whitish, scarred tissue.
• Scarring patterns
• Chronic follicular obstruction
What Treatment Options Exist for HS?
Management includes lifestyle modification, medications, and procedures. Weight management, smoking cessation, and avoiding friction can reduce flares. Medical options include antibiotics, hormonal therapies, and biologics targeting inflammatory pathways. Procedures such as deroofing or wide excision may be necessary for persistent lesions.
Supportive care for pain, drainage, and infection is essential.
Does Hidradenitis Suppurativa Affect More Than Just the Skin?
HS is increasingly recognized as a systemic inflammatory disease, not just a localized skin problem. It is associated with a number of comorbidities, which are co-occurring medical conditions. Awareness and screening for these associated conditions are vital for comprehensive patient care.
Commonly associated conditions include:
Metabolic Syndrome: A cluster of conditions including obesity, high blood pressure, high blood sugar, and abnormal cholesterol levels.
Arthritis: Various inflammatory joint diseases.
Inflammatory Bowel Disease (IBD): Conditions such as Crohn's disease and ulcerative colitis share common inflammatory pathways with HS.
Psychiatric and Mental Health Disorders: The chronic pain, disfigurement, and malodor associated with HS often lead to significant psychological distress, including anxiety, depression, and social isolation.