Hidradenitis Suppurativa (HS) is a chronic, inflammatory skin condition that affects areas of the body where skin rubs together and where there are apocrine sweat glands (which are associated with hair follicles). It is not an infection, it is not contagious, and it is not caused by poor hygiene.
In HS, hair follicles become blocked and inflamed, leading to painful, recurrent lumps, abscesses, and tunnels under the skin. It commonly affects the groin, inner thighs, under the breasts, and armpits. For many women, the groin is a primary site, which is why a gynaecologist may be involved in care.
HS is a long-term (chronic) condition with periods of flare-ups and remission. It can significantly impact quality of life, causing pain, embarrassment, and social isolation. While there is no cure, effective treatments can control symptoms, prevent new flares, and manage scarring.
Common Symptoms
- Symptoms typically start after puberty and may worsen around menstruation.
- Stage 1 (Early):
Single or multiple, painful, pea-sized “blind boils” or firm lumps under the skin.
They may either go away on their own or rupture and drain pus. - Stage 2 (Moderate):
Recurrent abscesses that form in the same areas.
Tunnels (sinus tracts) form under the skin, connecting inflamed areas.
Significant scarring begins. - Stage 3 (Severe):
Widespread, interconnected tunnels and abscesses across an area.
Chronic drainage, severe scarring, and persistent pain.
Other Signs: Blackheads in clusters (“double-barrelled”), itching, and a sensation of heat in the affected area.
Causes & Risk Factors
The exact cause is unknown, but it involves a combination of factors:
Follicular Occlusion: Hair follicles become blocked with keratin (a skin protein).
Immune System Overreaction: The body’s immune system attacks the blocked follicles, causing severe inflammation.
Genetic Link: About one-third of people with HS have a family member with the condition.
Hormonal Influence: Flares are often linked to the menstrual cycle, suggesting hormones play a role.
Risk Factors:
More common in women (3:1 ratio).
Onset typically between puberty and age 40.
Smoking and Obesity are strongly associated with more severe disease.
Other inflammatory conditions like Crohn’s disease, PCOS, or metabolic syndrome.
Diagnosis
There is no specific blood test or scan for HS. Diagnosis is made clinically by a doctor (often a dermatologist or experienced gynaecologist) based on:
Physical Examination: Looking at the typical lesions, their location, and the presence of scars or tunnels.
The “3 Key Features”:
Typical lesions (deep-seated painful nodules, abscesses).
Characteristic locations (groin, armpits, under breasts).
A chronic and recurring course.
Management & Treatment Options
Treatment is tailored to the severity (stage) and aims to reduce flares, pain, and scarring. A multidisciplinary team (dermatologist, gynaecologist, surgeon, dietitian) is often best.
Lifestyle & Self-Management
Weight Management: If overweight, even modest weight loss can reduce friction and inflammation.
Smoking Cessation: Essential, as smoking worsens inflammation.
Gentle Skin Care: Use antiseptic washes (e.g., benzoyl peroxide, chlorhexidine). Avoid shaving affected areas; use clippers instead. Wear loose-fitting, breathable cotton clothing.
Medical Treatments:
Topical: Prescription antibiotic creams (clindamycin).
Oral Antibiotics: Long-term courses (e.g., doxycycline, clindamycin + rifampin) for their anti-inflammatory effect.
Hormonal Therapies: Combined oral contraceptive pill or anti-androgen medication (like spironolactone) can help some women.
Biologic Therapy (Advanced Treatment): Adalimumab is an injectable medication that targets the specific inflammation in HS. It is approved for moderate-to-severe cases.
Other Medications: Metformin, retinoids (like acitretin), or steroids for flares.
Surgical & Procedural Treatments:
Incision & Drainage: Only for acute, painful abscesses (provides immediate relief but high recurrence).
Deroofing: Removing the “roof” of a tunnel to allow it to heal from the bottom up.
Wide Local Excision: Surgically removing the entire affected skin area, followed by closure or grafting. This is the most definitive procedure to prevent recurrence in that specific spot.
Living with HS & Long-Term Outlook
Chronic Nature: HS requires long-term management. Finding the right treatment combination takes time.
Pain Management: Chronic pain is a major part of HS. Discuss pain management strategies with your doctor.
Mental Health: The condition can lead to depression, anxiety, and social withdrawal. Seeking psychological support is a crucial part of care.
Cancer Risk: There is a very slightly increased risk of squamous cell carcinoma developing in long-standing, severely scarred HS areas after many years. Regular skin checks are advised.
Frequently Asked Questions (FAQs)
Q: Is HS caused by being dirty?
A: No. HS is an inflammatory disease, not an infection caused by dirt. Over-washing or scrubbing can actually irritate the skin further.
Q: Can I pass it to my partner through sex?
A: No. HS is not a sexually transmitted infection (STI). It is an autoimmune-inflammatory condition and is not contagious in any way.
Q: Will changing my diet help?
A: It may for some. While no universal “HS diet” exists, some people find that avoiding dairy, brewer’s yeast (in bread, beer), or high-sugar foods reduces flares. A dietitian can help guide an elimination diet.
Q: Is HS a form of acne?
A: It is sometimes called “acne inversa,” but it is a distinct condition. It involves deeper inflammation and scarring than common acne.
Q: Should I pop the lumps?
A: Do not squeeze or pop lesions. This can force bacteria deeper, worsen inflammation, cause more scarring, and spread the tunnels. Let them drain on their own or be treated by a professional.
eGynaecologist Advice
- You must adopt a gentle skin care routine and wear non-irritating, loose clothing to minimize friction and trauma in the affected areas. You should seek a referral to a Dermatologist, as they are the specialists in managing HS. A multidisciplinary clinic that includes gynaecology is ideal for groin involvement.
- You must stop smoking if you are a smoker. This is one of the most important modifiable factors to improve your condition and treatment response.
- You should be assessed for commonly associated conditions like metabolic syndrome, PCOS, depression, and inflammatory bowel disease, as part of your comprehensive care.
