Hidradenitis suppurativa (HS) is a chronic inflammatory disease causing painful nodules, abscesses, and scarring tunnels in skin-fold areas: the armpits, groin, buttocks, and under the breasts. It affects approximately 1–4% of the population and is profoundly underdiagnosed, with an average diagnosis delay of 7 years.
What Causes HS?
HS involves abnormal follicular occlusion and inflammatory response, not infection. Key factors include:
- Follicular plugging, the hair follicle becomes blocked, ruptures, and spills contents into surrounding tissue
- Immune dysregulation, an overactive inflammatory response drives chronic tissue damage
- Genetic predisposition, HS runs in families
- Hormonal factors, HS often begins around puberty and fluctuates with hormones
- Obesity, friction and metabolic inflammation worsen HS, though it also occurs in normal-weight individuals
Contrary to common misconception, HS is not caused by poor hygiene.
Physical and Psychological Impact
HS causes significant pain, drainage, and malodor that profoundly affects employment, relationships, and mental health. Quality of life scores in HS patients rival those of patients with serious cardiovascular disease.
Staging
- Stage I: Single or multiple abscesses without sinus tracts or scarring
- Stage II: Recurrent abscesses with sinus tracts and scarring
- Stage III: Multiple interconnected sinus tracts and abscesses, diffuse involvement
Treatment
Antibiotics (tetracyclines, rifampicin combinations) reduce inflammation. Biologic therapy, adalimumab (Humira) and secukinumab, are FDA-approved for moderate to severe HS. Surgical options include deroofing and wide excision for advanced disease.