Hidradenitis suppurativa

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Hidradenitis suppurativa is a chronic inflammatory skin condition characterized by recurrent follicular inflammation, typically in the intertriginous areas. Manifestations include painful skin lesions (nodules and abscesses), draining sinus tracts, and scarring; the severity of symptoms varies. The disease typically affects young adults. The exact etiology is unknown but likely multifactorial and thought to involve blockage of hair follicles. Diagnosis is clinical and treatment includes wound care, pain management, and pharmacotherapy. Psychological support may be required for mental health conditions that can be associated with hidradenitis suppurativa. Surgical interventions may be needed for severe and/or recurrent disease. Complications include disfigurement resulting from excessive scarring, bacterial superinfection, and, in affected areas, cutaneous squamous cell carcinoma.

• Prevalence: 0.1–2%
• Average age of onset: 18–39 years
• More common in:
  • Women
  • Individuals of African descent
  • Individuals with a family history of hidradenitis suppurativa

Epidemiological data refers to the US, unless otherwise specified.

The exact etiology of hidradenitis suppurativa is unknown, but the following factors may contribute to the development and/or severity of the disease: ^[2][3][4]

• Genetic predisposition to:
  • Dysregulation of signaling pathways that promote follicular hyperkeratinization
  • Dysregulation of the immune system → elevated levels of proinflammatory cytokines
• Hormonal imbalances
• Environmental factors
  • Tobacco smoking
  • Obesity
  • Bacterial colonization of hair follicles ^[5]
  • Use of certain medications (e.g., lithium, levonorgestrel) ^[6]

Blockage of hair follicle → dilation and rupture → spilling of follicular contents into dermis → inflammatory response → abscess formation and destruction of the pilosebaceous unit ^[2][3][4]

• Localized in intertriginous areas containing apocrine glands (most commonly the axillae, groin, inner thigh, perineal and perianal areas)
• The first lesion is usually a solitary painful inflammatory nodule that progresses to an abscess that may open or regress spontaneously.
• Sinus tracts may form between multiple recurrent nodules and drain foul-smelling, seropurulent discharge.
• Development of open ; and closed comedones
• Scarring ranges from small, individual acneiform scars to thick scarred plaques that affect larger areas of skin.

Diagnosis is clinical, based on both of the following. ^[2][3][4]

• Clinical features of hidradenitis suppurativa, including:
  • Characteristic skin findings
  • Involvement of intertriginous areas
  • Recurrent symptoms
• Exclusion of differential diagnoses for hidradenitis suppurativa; studies may include:
  • Bacterial culture (if the patient has a fever and/or signs of cellulitis) ^[2][3]
  • Skin biopsy (to differentiate from similar lesions seen in other conditions) ^[3]

• Severe acne vulgaris (i.e., acne conglobata)
• Primary skin and soft tissue infections: e.g., folliculitis, bacterial abscess
• Other conditions with skin lesions that affect the genitourinary region, e.g.:
  • Granuloma inguinale
  • Pyoderma gangrenosum (seen in Crohn disease and other inflammatory bowel diseases)
  • Lymphogranuloma venereum
  • Pilonidal cyst

The differential diagnoses listed here are not exhaustive.

General principles ^[2][3][4]

Hidradenitis suppurativa is a chronic condition with no cure and requires chronic disease management.

• Provide supportive care, including pain management.
• Screen for and manage hidradenitis suppurativa-associated comorbidities.
• Initiate first-line pharmacological therapies, which may include:
  • Topical or intralesional therapies
  • Systemic therapies (e.g., oral antibiotics, hormonal therapy)
• Refer patients with moderate, severe, or refractory disease to dermatology for management. ^[4]

Supportive care ^[2][3][7]

• Patient education on disease process and management
• Recommend smoking cessation if relevant. ^[2][4]
• Wound care
  • Warm compresses
  • Cover open wounds.
  • Discuss ways to improve physical comfort, e.g., wearing loose-fitting clothes.
• Pain management
  • Optimize control of disease.
  • Consider multimodal approaches with nonpharmacological analgesia.
  • According to the WHO analgesic ladder, consider: ^[4]
    • Topical analgesia (e.g., lidocaine)
    • Nonopioid analgesics (e.g., NSAIDs, acetaminophen)
    • Opioid analgesics in certain patients with severe pain, for a limited duration

Hidradenitis suppurativa-associated comorbidities ^[2][3][4]

Screen for and manage the following conditions that commonly co-occur with hidradenitis suppurativa:

• Metabolic syndrome and its components
  • Obesity
  • Diabetes mellitus type 2
  • Hypertension
  • Dyslipidemia
• Polycystic ovarian syndrome
• Immune-mediated conditions
  • Inflammatory bowel disease
  • Inflammatory arthropathies
• Mental health conditions
  • E.g., major depressive disorder, suicidal thoughts or behavior, anxiety disorders
  • May result from social isolation and reduced quality of life due to malodorous discharge, pain, and/or disfigurement
• Sexual dysfunction
• Squamous cell carcinoma: may occur in areas affected by hidradenitis suppurativa, especially on the perineum and buttocks

Recommend weight reduction to patients with obesity, as it may improve the severity of disease. ^[2]

Pain, malodorous drainage, and scarring often negatively impact the patient's quality of life. ^[3][4]

Pharmacological therapy ^[2][3][7]

Treatment may include different combinations of the following, depending on the severity of disease:

Localized therapies

• Topical antibiotics: e.g., clindamycin, dapsone
• Topical resorcinol
• Intralesional triamcinolone
• Antiseptic washes: e.g., chlorhexidine, benzoyl peroxide, zinc pyrithione

Systemic therapies

• Oral antibiotics: e.g., tetracyclines, clindamycin PLUS rifampin, dapsone
• Hormonal therapies: e.g., spironolactone, combined oral contraceptives, metformin ^[7]
• Oral retinoids (limited efficacy): e.g., acitretin, isotretinoin ^[7]
• Oral biologics: e.g., TNF inhibitors (adalimumab or infliximab), anakinra
• Immunosuppressants ^[7]

Procedural interventions ^[2][3][4]

For lesions refractory to pharmacological therapy, any of the following may be performed:

Acute lesions

• Incision and drainage of abscesses
• Punch debridement of small lesions ^[2]

Chronic lesions

• Deroofing of recurrent nodules, abscesses, and sinus tracts ^[2][8]
• Wide local excision with skin grafts for extensive, chronic disease and scarring
• Laser therapy (e.g., Nd:YAG laser, CO₂ laser)

• Excessive scarring, which may lead to:
  • Contractures ^[3]
  • Lymphedema as a result of lymphatic obstruction (rare): typically affects the anogenital region ^[9]
• Bacterial superinfection ^[2][3]
• Squamous cell carcinoma ^[2]

We list the most important complications. The selection is not exhaustive.

• Chronic with a high rate of recurrence ^[4][10]
• Decreases quality of life ^[10]