Hidradenitis suppurativa

Overview

Hidradenitis suppurativa (hi-drad-uh-NIE-tis sup-yoo-ruh-TIE-vuh) is a skin condition that causes small, painful lumps to form under the skin. The lumps can break open, or tunnels can form under the skin. The condition mostly affects areas where the skin rubs together, such as the armpits, groin, buttocks and breasts.

Hidradenitis suppurativa tends to start after puberty. It can persist for many years and worsen over time, with serious effects on your daily life and emotional well-being. Medications and surgery can help manage symptoms and prevent complications.

Hidradenitis suppurativa in armpit

Hidradenitis suppurativa usually appears as one or more red, tender bumps that fill with pus. It most commonly occurs in the armpits (shown), groin, between the buttocks and under the breasts.

Symptoms

Hidradenitis suppurativa can affect one spot or multiple areas of the body. Signs and symptoms of the condition include:

  • Blackheads. Small pitted areas of skin containing blackheads — often appearing in pairs or a "double-barreled" pattern — are a common feature.
  • Painful pea-sized lumps. The condition usually starts with a single, painful lump under the skin that persists for weeks or months. Later more bumps form. They usually appear in areas with hair follicles with many oil and sweat glands, such as the armpits, groin and anal area. They also occur where skin rubs together, such as the inner thighs, breast and buttocks.
  • Tunnels. Over time, tracts connecting the lumps may form under the skin. These wounds heal very slowly, if at all, and can leak pus, which may have an odor.

Some people with this condition experience only mild symptoms. Excess weight, stress, hormonal changes, heat or humidity may worsen symptoms. In women, the disease severity may lessen after menopause.

When to see a doctor

Early detection of hidradenitis suppurativa is key to getting effective treatment. See your doctor if your condition:

  • Is painful
  • Doesn't improve in a few weeks
  • Returns within weeks of treatment
  • Appears in several locations
  • Flares often

If you've already received a diagnosis of hidradenitis suppurativa, keep in mind that the warning signs of a disease flare are often similar to those that occurred originally. Also pay attention to any new signs or symptoms. These may indicate either a flare or a complication of treatment.

You may need to see a specialist in skin conditions (dermatologist) or a surgeon for long-term care.

Causes

The exact cause of hidradenitis suppurativa isn't known. It develops when hair follicles in the skin become blocked. Experts think it could be connected to hormones, inherited genes and immune system problems. Smoking, excess weight and metabolic syndrome also might play a role.

Hidradenitis suppurativa is not caused by an infection or being unclean, and it can't be spread to other people.

Risk factors

Factors that increase your chance of developing hidradenitis suppurativa include:

  • Age. Hidradenitis suppurativa most commonly occurs in women between the ages of 18 and 29. People who develop the condition at an early age may be at increased risk of developing more widespread disease.
  • Your sex. Women are more likely to develop hidradenitis suppurativa than are men.
  • Family history. A tendency to develop hidradenitis suppurativa can be inherited.
  • Obesity. Several studies have shown a relationship between being overweight and hidradenitis suppurativa.
  • Smoking. Smoking tobacco has been linked to hidradenitis suppurativa.

Complications

Persistent and severe hidradenitis suppurativa often causes complications, including:

  • Infection. The affected area is susceptible to infection.
  • Scars and skin changes. The wounds may heal but leave rope-like scars or pitted skin.
  • Restricted movement. Sores and scar tissue may cause limited or painful movement, especially when the disease affects the armpits or thighs.
  • Obstructed lymph drainage. The most common sites for hidradenitis suppurativa also contain many lymph nodes. Scar tissue can interfere with the lymph drainage system, which may result in swelling in the arms, legs or genitals.
  • Social isolation. The location, drainage and odor of the sores can cause embarrassment and reluctance to go out in public, leading to sadness or depression.

Diagnosis

Your doctor will ask you about your signs and symptoms, examine your skin and take your medical history.

No laboratory test is available to diagnose hidradenitis suppurativa. But if pus or drainage is present, your doctor might send a sample of the fluid to a laboratory for testing. This can help rule out other conditions, such as an infection.

Treatment

Treatment with medications, surgery or both may help control symptoms and prevent complications. No single option has been proven to be completely reliable, and research continues to determine the best combination. Talk with your doctor about the risks and benefits of the various treatment options and developing an approach tailored to your situation.

Expect to have regular follow-up visits with your dermatologist or a multidisciplinary health care team that can provide the comprehensive care often required by people with hidradenitis suppurativa.

Medications

Your doctor might prescribe one or more of the following types of medications:

  • Antibiotic creams. Mild symptoms might be managed with topical creams that fight infections, such as clindamycin and gentamicin.
  • Systemic drugs. For more widespread diseases, antibiotics taken by mouth, such as clindamycin, rifampin and doxycycline, may help. An injection of adalimumab may be used for moderate to severe disease, though it may take about two weeks to notice any benefit. And small studies have shown the injectables infliximab and anakinra to be effective.
  • Pain medication. If over-the-counter pain relievers don't help, your doctor may prescribe a stronger type.

Surgery

Surgical options include:

  • Uncovering the tunnels. Known as unroofing, this procedure involves removing tissue to expose the tunnels under the skin. It is used for people with moderate and severe hidradenitis suppurativa. This solution usually doesn't have to be repeated.
  • Punch debridement. This procedure is also called limited unroofing and may be used to remove a single inflamed nodule.
  • Tissue-sparing excision with electrosurgery. This may be an option for people with severe hidradenitis suppurativa. It combines skin-tissue-sparing removal (excision) of damaged tissue with electrosurgical peeling.
  • Laser therapy. Carbon dioxide laser can be used to make lesions go away.
  • Surgical removal. Surgical treatment may be an option for people with persistent or severe symptoms. It involves removing all of the affected skin. A skin graft may be necessary to close the wound. Even after you have surgery, sores may still occur in other areas. In men whose condition involves the area between the anus and scrotum, surgical removal of the scrotum is almost always necessary.
  • Incision and drainage. Surgical drainage is no longer considered an effective option for treating hidradenitis suppurativa. The method may be considered to provide short-term pain relief, but sores tend to flare again.

Emerging therapies

More studies of surgical options are needed to improve hidradenitis suppurativa care. In particular, good-quality clinical trials are needed to evaluate the timing or surgery and type of surgical procedure. Other interventions being studied are topical antiseptics, novel biological therapies and further study of adalimumab.

Lifestyle and home remedies

Mild hidradenitis suppurativa may be treated with only self-care measures. But self-care is also an important complement to any medical treatment you may be getting. The following suggestions may help relieve discomfort, speed healing or prevent outbreaks:

  • Follow a daily skin care routine. Gently wash your body with a nonsoap cleanser such as Cetaphil. It may help to use an antiseptic wash such as chlorhexidine 4% when showing. First try it once a week, then increase usage up to once a day if your skin tolerates it well.

    When washing, avoid using washcloths, loofahs or other items on affected areas, as they can irritate skin. Then apply an over-the-counter antibiotic cream or a cream containing the antimicrobial benzalkonium chloride. It might also help to apply extra absorbent powder or zinc oxide.

  • Manage your pain. Gently applying a wet, warm washcloth, tea bag or other sort of compress can help reduce swelling and ease pain. Keep it on for about 10 minutes.

    Ask your doctor to recommend the most appropriate pain reliever. And talk with your doctor about how to properly dress and care for your wounds at home.

  • Avoid tight clothes and irritating products. Wear loose, lightweight clothes to reduce friction. Some women find that using tampons rather than sanitary pads causes less friction with the skin. Use detergents and other products that are free of perfumes, dyes and enzymes.
  • Avoid injuring the skin. For example, don't squeeze the pimples and sores. And stop shaving affected skin.
  • Keep a healthy weight and stay active. Not being at a healthy weight can worsen the symptoms of hidradenitis suppurativa. Try to find activities that don't irritate your skin.
  • Consider altering your diet. Hidradenitis symptoms may be worsened by diets that include dairy, red meat and foods with a high glycemic index.
  • Avoid all tobacco products. If you smoke, try to quit. Smoking and other tobacco use can worsen the symptoms of hidradenitis suppurativa.

Coping and support

One of the greatest challenges of living with hidradenitis suppurativa may be coping with pain and embarrassment. Painful sores might affect your sleep, mobility or sex life. If the sores are draining pus, they can smell, despite good self-care. You might feel anxious and become withdrawn, self-conscious or depressed.

Try to find support among your family and friends. You may also find the concern and understanding of other people with hidradenitis suppurativa comforting. Ask your doctor for a referral to a mental health professional or contact information for a support group.

Preparing for an appointment

You may start by seeing your primary care doctor. He or she may refer you to a doctor who specializes in treating skin diseases (dermatologist). Depending on the severity of your condition, your care may also involve specialists in colorectal surgery, plastic surgery or digestive diseases (gastroenterology).

Here's some information to help you get ready for your appointment.

What you can do

Before your appointment make a list of:

  • Symptoms you've been experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment
  • All medications, vitamins and supplements you take, including doses
  • Questions to ask your doctor

For hidradenitis suppurativa, some basic questions to ask your doctor include:

  • What's the most likely cause of my symptoms?
  • Are there other possible causes?
  • Do I need any tests?
  • How long will my condition last?
  • What treatments are available, and which do you recommend?
  • What side effects can I expect from treatment?
  • Is this condition related to another medical disorder?
  • Do you have any brochures or other printed materials that I can take with me? What websites do you recommend?

What to expect from your doctor

Your doctor is likely to ask you a number of questions, such as:

  • When did your symptoms begin?
  • What did the skin lumps look like when they started?
  • Do they come back in the same spots?
  • Are your symptoms painful?
  • Have your parents or siblings ever had this problem?
  • What, if anything, seems to improve your symptoms?
  • What, if anything, seems to worsen your symptoms?
  • Do you smoke or use tobacco products?

Last Updated May 16, 2019


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