Hidradenitis suppurativa is a chronic, recurrent inflammatory condition of the hair follicle, that occurs in genetically predisposed individuals and is influenced by environmental factors such as smoking and obesity.
Hidradenitis suppurativa is characterized by the presence of blackheads and one or more red, soft lumps (lesions). Lesions often enlarge, open and secrete pus. Scarring can occur as a result after a number of relapses.
This condition is often considered a severe form of acne . Hidradenitis suppurativa occurs deep in the skin around the oil glands (sebaceous) and hair follicles . The affected body parts are usually the groin and armpits, which are also the main locations of the apocrine sweat glands
Synonyms of Hidradenitis Suppurativa also known as, acne conglobata, acne inversa, apocrine acne, Fox-den disease
Hidradentis Suppurativa lesion in the labial region in female causing multiple sinuses and scarring of the labial and perineal skin
The physiopathogenesis of the disease is currently understood as:
I) hyperkeratosis and follicular occlusion;
II) dilatation of the pilosebaceous unit;
III) rupture and release of the follicular contents into the dermis;
IV) secondary inflammatory reaction;
V) influx of inflammatory cells and release of new cytokines, perpetuating the process (raise in TNFα, IL-6, IL-10, IL-12, IL-23 and IL-17); with the formation of abscesses and fistulas.
Sex steroids seem to influence the course of the disease with onset after puberty, female predominance and perimenstrual exacerbation; however, their contribution to the pathogenesis is still unclear.1
This disease occurs from puberty to young adulthood. The overall prevalence is around 1% to 4% of population. The ratio of women to men is 3: 1.
Smoking and obesity are risk factors for this disease . This disease is also often preceded by trauma or microtrauma, for example a lot of sweat, use of deodorant or clipped armpit hair .
Pathogenesis of Hidradenitis suppurativa
Co-morbidities or other associated conditions with Hidradenitis Suppurativa
Hidradenitis suppurativa can be associated to many diseases, such as follicular occlusion syndrome (acne conglobata, dissecting
cellulitis and pilonidal sinus); auto-inflammatory diseases such as SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis),
PASH (pyoderma gangrenosum, acne and suppurative hidradenitis) and PAPASH (pyogenic arthritis, pyoderma gangrenosum, acne and suppurative hidradenitis) syndromes.
Some bacteria have been identified in cultures taken from suppurative hidradenitis lesions , including Streptococcusviridans, Staphylococcus aureus , anaerobic bacteria ( Peptostreptococcus species, Bacteroi desmelanino genicus, and Bacteroides corrodens), Coryne formbacteria, and Gram-negative rods.
The initial complaints felt by the patient are itching, erythema, and local hyperhidrosis. Without treatment this disease can develop and the patient feels pain in the lesion.
Smoking, obesity , sweating a lot, deodorant use, cutting armpit hair
Simple Physical Examination and Support Results (Objective)
A rash in the form of a node with signs of acute inflammation , can then be softened into an abscess, and break down to form a fistula and is called suppurative hidradenitis . In the chronic can form multiple abscesses, fistulas, and sinuses. There is leukocytosis.
Location of predilection in the axilla, groin, gluteal, perineum and breast area . Although the disease in the axilla is often mild, in the perianal it is often progressive and recurrent.
There are two classification systems to determine the severity of suppurative hidradenitis , namely the Hurley and Sartorius classification systems.
Hurley classified patients into three groups based on the presence and extent of scarring and sinuses.
Stage I : solitary or multiple lesions, characterized by abscess formation without sinus ducts or scarring.
Stage II : single or multiple lesions with recurrent abscesses, characterized by the formation of sinus tracts and scar tissue.
Stage III : the most severe stage, several interconnected channels and abscesses involving the entire anatomical area (eg armpits or groin).
Sartorius score. Scores are obtained by counting the number of skin lesions and the level of involvement at each anatomic location . More severe lesions such as fistulas are given a higher score than mild lesions such as abscesses. Scores from all anatomic locations are added to get a total score.
Furuncle , carbunkel , epidermoid cyst or dermoid cyst, Erysipelas , inguinal granuloma, lymphogranuloma venereum, scrofuloderma
Scarring at the lesion site.
Chronic genitofemoral inflammation can cause stricture in the anus, urethra or rectum.
Genital edema that can cause functional disorders.
Squamous cell carcinoma can develop in patients with a long history of the disease , but is rare.
Comprehensive Management (Plan)
Systemic antibiotics Systemic
antibiotics for example in combination with rifampicin 600mg daily (in a single dose or divided dose) and clindamycin 300mg twice a day show promising treatment results. The dosage is 50-150mg / day as monotherapy, erythromycin or tetracycline 250-500 mg 4x daily, doxycillin 100 mg 2x daily for 7-14 days.
Systemic corticosteroids Systemic
corticosteroids such as triamcinolone, prednisolone or prednisone
If an abscess has formed, an incision is made .
Advice for patient with Hidradenitis Suppurativa
- Reducing weight for obese patients .
- Quit smoking.
- Do not shave on acne prone skin because shaving can irritate the skin.
- Maintain cleanliness of the skin.
- Wear loose clothing to reduce friction
- Bathing with soap and antiseptic or antiperspirant.
1. Magalhães RF, Rivitti-Machado MC, Duarte GV, Souto R, Nunes DH, Chaves M, Hirata SH, Ramos AMC. Consensus on the treatment of hidradenitis suppurativa - Brazilian Society of Dermatology. An Bras Dermatol. 2019 Apr;94(2 Suppl 1):7-19. doi: 10.1590/abd1806-4841.20198607. Epub 2019 Jun 3. PMID: 31166401; PMCID: PMC6544037.