Hidradenitis suppurativa

What is hidradenitis suppurativa?

Hidradenitis suppurativa (HS), also called acne inversa, is a long-term condition in which there is inflammation (redness and swelling) of certain sweat glands. These glands are found mainly in the armpits, breasts, abdominal fold, groin, genital area, and buttocks. The inflammation causes painful lumps or boils that can leak pus and lead to scarring.
HS can have a significant psychological impact, and many patients suffer from anxiety, depression, and poor self-esteem.

What does hidradenitis suppurativa look and feel like?

HS can affect anyone but is more common in women and in skin of colour. 

HS causes painful boils often starting in early adulthood.  Boils may cause problems with regular activities such as sitting or walking. Discharge of pus can be a problem and may require daily dressings.

Longer term HS leads to the development of tunnels under the skin and open wounds that are slow to heal and often result in scars. 

What causes hidradenitis suppurativa?

The cause of HS is poorly understood. The processes involved include:

• Blockage of the hair follicles
• An altered microbiome – millions of bacteria and other microorganisms live on our skin and play an important role in our overall health. In HS it is believed that the normal healthy microbiome is altered
• Inflammation causing swelling and then rupture of the glands 

In approximately one third of cases someone else in the family is affected. HS is NOT caused by poor hygiene.

What else can contribute to hidradenitis suppurativa?

• Hormones may be involved; HS can be worse before menstrual periods and can improve after the menopause
• An over-active immune system is involved causing inflammation
• HS is more common in people who are overweight
• Up to 60% of people affected by HS are smokers

Conditions associated with hidradenitis suppurativa

• If you feel depressed or anxious it is important to tell a healthcare professional
• There may be a link with acne and dissecting scalp cellulitis (boils and inflammation of the scalp), as well as pilonidal sinus (a chronic abscess at the top of the buttock crease)
• The metabolic syndrome, which is associated with high cholesterol, high blood pressure, and diabetes
• Inflammatory arthritis, especially of the low back, which can lead to pain, stiffness and restricted movement of the lower back
• Inflammatory bowel disease such as Crohn disease and ulcerative colitis, causing persistent diarrhoea, blood in the stools, or abdominal pain

Things you can do to help yourself

• If relevant, lose weight and stop smoking
• Avoid tight clothing and tight underwear
• Use antibacterial or antiseptic washes
• Avoid shaving affected areas, such as underarms
• Consider joining a support group
• If you develop a sudden flare with a painful boil, the following may help:
  • A warm flannel applied to the affected area, or taking a bath, may encourage drainage of pus
  • Painkillers. If you can take non-steroidal anti-inflammatories (NSAIDs), such as ibuprofen, these can help reduce pain and inflammation
  • A steroid cream can sometimes reduce the inflammation
  • If the boil is not settling you will need to contact a healthcare professional who may arrange for the boil to be drained surgically or injected with a steroid. If the inflammation is caused by an infection a short course of antibiotics may be prescribed 

Make an appointment at your GP surgery

Treatment for HS is often long-term and should be started soon after the condition arises. Delay in starting treatment can lead to the HS being more difficult to treat in the long-term.

Ideally your healthcare professional should provide you with all of the following:

• An antibiotic tablet that also has an anti-inflammatory action, initially for 3 months
• An antiseptic wash
• A potent (strong) steroid cream to use for a flare
• Dressings should be prescribed for people with HS experiencing leaking of fluid. The most useful type of dressing is one with a non-sticking absorbent part and a border that sticks to your skin 

Other treatments sometimes used include metformin (a tablet normally used to treat diabetes), certain oral contraceptives and spironolactone in women.

When you visit your GP surgery ask them to look at the HS guidelines in the A-Z of Clinical Conditions at www.pcds.org.uk for detailed advice on treatment. 

If you are overweight you will be advised on lifestyle changes to help lose weight, and you may be offered medication.

Referral to a specialist

If your HS is not adequately controlled by the treatment provided by your Primary Healthcare professional, you will need to be referred to a specialist, usually a dermatologist in Secondary Care. 

What will happen when you are referred?

As well as the treatments already discussed, other medical treatments sometimes used include retinoids (vitamin A derived tablets) such as acitretin, dapsone, and biologic injections which help supress the immune system.

Surgical procedures may be considered for active areas of HS that have failed to respond to medical therapy. Healing can be slow after surgical procedures as the skin is normally left to heal itself. 

Helping with other skin conditions

If you, a family member, or friend have an undiagnosed skin condition; or you want to learn more about how to treat skin conditions, please view our short video on how to get the best from this website.