Understanding Hidradenitis Suppurativa - Causes, Treatments and Impact on Patients
- Dr Bryan McDonald
- Jul 10
- 3 min read
Hidradenitis suppurativa (HS) is a chronic skin condition that causes painful lumps under the skin, often in areas where skin rubs together. These lumps can lead to abscesses, openings in the skin that can drain pus/fluid and scarring of the skin. Despite its significant impact on quality of life, HS remains under-recognized and misunderstood. This article explores the causes, biological mechanisms, diagnosis challenges, treatment options, and the broader effects on patients living with this condition.
Causes and Risk Factors of Hidradenitis Suppurativa
The exact cause of hidradenitis suppurativa is not fully understood, but several factors contribute to its development:
Follicular Occlusion: HS begins with blockage of hair follicles, leading to inflammation and infection.
Genetic Predisposition: About one-third of patients report a family history, suggesting a hereditary component.
Hormonal Influences: HS often starts after puberty and may worsen with hormonal changes, indicating hormones play a role.
Lifestyle Factors: Smoking and obesity are strongly linked to HS. Smoking may worsen inflammation, while excess weight increases skin friction and may have other triggering roles.
Immune System Dysfunction: HS is considered an inflammatory disorder where the immune system reacts abnormally, causing chronic inflammation.
Understanding these factors helps identify individuals at risk and guides early intervention strategies.
Biological Processes Behind Hidradenitis Suppurativa
HS develops through a series of biological events:
Follicular Blockage
Hair follicles become clogged with keratin and debris, preventing normal drainage.
Follicle Rupture
Blocked follicles swell and rupture, releasing contents into surrounding tissue.
Inflammatory Response
The immune system responds aggressively, causing painful nodules and abscesses.
Chronic Inflammation and Scarring
Repeated cycles of inflammation lead to sinus tract formation (tunnel-like scars) and permanent skin damage.
Research shows elevated levels of inflammatory molecules such as tumor necrosis factor-alpha (TNF-α) in affected skin, which has led to targeted therapies that block these molecules.
Conditions That Can Be Confused with Hidradenitis Suppurativa
HS shares symptoms with several other skin conditions, making diagnosis challenging. Key conditions to consider include:
Boils (Furuncles)
Usually isolated infections of hair follicles, unlike HS which is chronic and recurrent.
Carbuncle
A cluster of boils connected under the skin, but lacks the sinus tracts seen in HS.
Pilonidal Cyst
Occurs near the tailbone (bottom of the spine) but is localized. May occur along with HS.
Infected Epidermoid Cysts
These cysts can become inflamed but do not typically form the tunnels characteristic of HS.
Distinguishing HS requires careful clinical examination and patient history, focusing on lesion location, recurrence, and presence of sinus tracts.
Treatment and Management Strategies
Managing HS involves a combination of lifestyle changes, medications, and sometimes surgery. Treatment aims to reduce inflammation, prevent new lesions, and improve quality of life.
Lifestyle Modifications
Weight Management
Losing weight reduces skin friction and inflammation.
Smoking Cessation
Quitting smoking can decrease disease severity.
Hygiene and Clothing
Wearing loose, breathable clothing and maintaining skin hygiene helps reduce irritation/friction.
Medications
Topical Treatments
Antibiotics like clindamycin can reduce bacterial load and inflammation, whilst medications, such as benzoyl peroxide and retinoids can help to unblock the follicles.
Oral Antibiotics
Long courses of antibiotics such as tetracyclines help control infection and inflammation.
Hormonal Therapy
Anti-androgens or oral contraceptives may benefit some patients, especially women.
Biologic Drugs
TNF-α inhibitors like adalimumab have shown effectiveness in moderate to severe HS by targeting immune pathways. Secukinumab is another drug that is also NICE approved for HS. Further medications are presently under research.
Pain Management
Analgesics and anti-inflammatory drugs help control discomfort.
Surgical Options
Incision and Drainage
Provides temporary relief but does not prevent recurrence.
Laser Therapy
Laser hair removal may help prevent flares of HS.
Wide Excision
Removing affected skin areas may be necessary in severe cases to prevent recurrence and this removes the scarred skin.
Choosing the right treatment depends on disease severity, patient preferences, and response to previous therapies.
Complications and Psychosocial Effects
HS can lead to several complications beyond the skin:
Physical Complications
Chronic wounds, scarring, restricted movement due to pain, and secondary infections.
Psychological Impact
Patients often experience depression, anxiety, and social isolation due to pain, odor, and visible lesions.
Quality of Life
HS affects daily activities, work, and intimate relationships, making comprehensive care essential.
Support groups and counseling can help patients cope with the emotional burden of HS.
Hidradenitis suppurativa is a complex condition that requires a multifaceted approach for effective management. Recognizing its causes and biological mechanisms helps tailor treatments that reduce symptoms and improve patient well-being. If you or someone you know shows signs of HS, consulting a healthcare professional early can lead to better outcomes by preventing disease progression, and a more manageable disease course.
