Introduction:
Hidradenitis suppurativa is a hereditary long-term inflammatory skin condition of the hair follicles and sweat glands. It begins as a boil-like bump on the skin. When left untreated, these bumps worsen, traverse deep into the skin, and progress to stiff, painful lumps or boils. These boils break open over time and leave a scar after healing. The cause of hidradenitis suppurativa is unknown. The most commonly affected areas are the groin, genitals, on the bottom, and surrounding the anus, breasts, and armpits. Infection of the lumps with bacteria can result in secondary infections which need to be treated with antibiotics.
How Is Hidradenitis Suppurativa Otherwise Known?
This condition is otherwise known as:
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Apocrinitis.
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Acne inversa.
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Verneuil's disease.
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Velpeau's disease
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Suppurative hidradenitis.
What Causes Hidradenitis Suppurativa?
The cause of hidradenitis suppurativa is unknown. It might be a combination of genetic and environmental causes. Various factors have been known to cause the condition. They are:
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Blockage of specific sweat glands known as apocrine glands.
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Blockage of hair follicles in areas with a high concentration of apocrine glands (as in armpits and groin). The hair follicles comprise a fibrous protein called keratin. When the hair follicle is blocked, bacteria gets trapped, resulting in swelling and rupture of hair follicles.
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The onset of this condition is usually around puberty, but it can also manifest at any age following puberty. This is suggestive of the fact that sex hormones play a role in hidradenitis suppurativa. A majority of people with this condition also experience acne and hirsutism (excessive hair growth).
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Rarely, hidradenitis suppurativa may be associated with Crohn’s disease (a chronic condition that causes inflammation of the lining of the digestive system), especially if it develops around the skin near the anus or around the groin region.
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Genetic factors include NCSTN, PSEN1, or PSENEN gene mutations, which are required for chemical signaling pathways. The notch signaling pathway is vital for the average growth and maturation of hair follicles and other skin cells. Alteration of the genes mentioned above impairs the notch signaling pathway and develops nodules and results in skin inflammation.
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Hidradenitis suppurativa is a hereditary condition that occurs in about one in three cases. However, it is not a contagious condition.
What Are the Risk Factors for Hidradenitis Suppurativa?
Hidradenitis suppurativa is not transmitted from one person to another. If the condition is left untreated, the infection can migrate to the skin itself or into the blood. However, such conditions are very rare but can be very serious. The following are the risk factors:
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Smoking.
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Abnormal immune function or hormonal imbalance as in puberty or menopause.
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Using underarm deodorants.
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Shaving or using depilatory (a cosmetic preparation used in the removal of hair from the skin) products for hair removal.
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Dairy products and a white, sugary carbohydrate-rich diet.
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Wearing tight clothes or anything that easily clogs the pores.
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Inflammatory bowel diseases.
What Are the Symptoms of Hidradenitis Suppurativa?
It starts with mild itching and discomfort and appears as tender, red, firm pea-sized swollen areas. These swellings progress into boil-like bumps filled with pus and rupture within a few hours to days. A foul odor may also occur. A combination of blackheads, cysts, boil-like lumps, scarring, and pus-leaking channels in the skin may be produced.
Hidradenitis suppurativa can usually originate as a bump on the inner thigh and can be mistaken for a pimple on the inner thigh or in the armpit.
Scars may be present during healing. This swelling creates sinus tracts under the skin (pilonidal sinus) that may produce swelling and rupture in other areas. These sinus tracts may spread to the face, nape of the neck, back, inner thighs, and legs. Hidradenitis suppurativa affects the underarms, breasts, buttocks, groin, genitals around the anus, and the inner thigh.
How Is Hidradenitis Suppurativa Diagnosed?
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The hidradenitis suppurativa is diagnosed using the following tests:
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A thorough study of family history pertaining to skin problems is done.
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Full physical examination.
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Complete and differential blood count.
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A swab of the affected area may be obtained. This aids in diagnosis since the condition is not usually linked with the bacterial infections that cause skin infections.
However, there is no conclusive test to diagnose hidradenitis suppurativa.
How Is Hidradenitis Suppurativa Treated?
Even though there is no known treatment for hidradenitis suppurativa, prompt diagnosis, and treatment help prevent the disease and scar formation. Treatment is dependent on the severity of the lesion.
Mild disease can be managed using home remedies like:
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Bathing in a warm bath and using warm compression for 10 minutes.
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Cleaning with antiseptic wash (4 % Chlorhexidine), and antibacterial soaps to reduce bacterial load.
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Anti-inflammatory drugs like Ibuprofen, Naproxen, and Celecoxib can be taken.
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Loose-fitting clothes can be worn to prevent friction against the skin.
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Appropriate weight should be maintained. Obesity can cause more skin friction in the hidradenitis suppurativa-affected areas.
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Oral zinc gluconate, vitamins C, and D may strengthen the pores.
Moderate disease with pain can be treated by:
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Corticosteroids therapy to reduce pain and swelling.
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Anti-inflammatory drugs like Ibuprofen, Naproxen, and Celecoxib may be prescribed.
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Oral or topical antibiotics may be prescribed to treat hidradenitis suppurativa in the groin or other areas. Painful, inflamed, and pus-releasing lumps may be treated with a course of antibiotics taken for one to two weeks if the tests are indicative of a bacterial infection. Low doses of antibiotics may be prescribed to prevent inflammation in cases where bacterial infection is absent.
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Antibiotics in the form of capsules, creams, liquids, or tablets may be prescribed. Common antibiotics include Doxycycline, Lymecycline, Clarithromycin, or Erythromycin. Severe cases might require a blend of Rifampicin and Clindamycin.
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Adalimumab and Infliximab are immunosuppressive treatments that suppress the immune mechanism in moderate to severe lesions. Because of the risks of immunosuppression caused by these drugs, these are usually prescribed by the dermatologist (skin specialist) if other treatments are ineffective.
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In rare conditions, steroids like prednisolone may be prescribed to reduce severe inflammation. Steroids are administered as injections, tablets, or creams. Associated side effects of steroids include weight gain, mood swings, and poor sleep.
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Retinoids like acitretin (vitamin-A-based medicines), acne drugs, and birth control pills are sometimes prescribed when hormonal changes are noticed. Retinoids should be taken only if it is prescribed by a dermatologist (skin specialist). They have to be taken with care and are contraindicated during pregnancy. It is not commonly prescribed in women of child-bearing age since after stopping retinoids, one must refrain from getting pregnant for three years.
Severely affected patients are treated with surgical procedures as follows:
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The laser procedure may be preferred to clear new breakouts and the sinus tracts.
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De-roofing procedure.
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Abscess drainage.
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Excision of a larger skin area and scar tissue followed by grafting with healthy tissues.
What Are the Complications of Hidradenitis Suppurativa?
Hidradenitis suppurativa occurs in sequences throughout life, with consecutive breakouts and recoveries. The complications of hidradenitis suppurativa are:
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Abscess can arise from deep within the skin tissue.
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Continuous healing and scarring can make the skin thick, firm, and difficult to move.
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Continuous healing and scarring can cause fistulas (hollow passages) inside the body that can be painful and might require surgical repair.
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The recurrent abscesses can cause prolonged pain leading to social isolation and depression.
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In rare conditions, long-term abscesses on the buttocks can transform into squamous cell carcinoma.
How Can Hidradenitis Suppurativa Be Prevented?
As the cause is not known, the following simple steps can reduce the symptoms of hidradenitis suppurativa.
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Gaining a healthy weight.
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Refrain from smoking.
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Wear loose clothes.
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Take a warm bath.
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The affected areas should not be cut.
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The affected areas should be cleaned every day using antibacterial and antiseptic skin wash or soap containing triclosan or benzoyl peroxide.
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A warm fabric should be held on the lumps to drain the pus.
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One must avoid shaving the affected skin area and avoid perfume or deodorants in the affected areas. The laser hair removal technique can be effective and can help reduce the lesion in hair-bearing areas.
What Is the Prognosis of Hidradenitis Suppurativa?
There is no cure for hidradenitis suppurativa. Hence, the prognosis depends on the disease’s severity. Early diagnosis of the condition can help alleviate the symptoms with appropriate treatment. The need to change the dressings regularly and the associated pain and discomfort can impact the quality of one’s life and result in depression. Some have recurrent outbreaks for a lifetime and some have no symptoms when surgically treated. Rarely, hidradenitis suppurativa disappears without treatment.
Conclusion:
Hidradenitis suppurativa is a painful, lifetime, recurring skin condition due to the hair follicle and sweat gland duct obstruction and is challenging to manage. It can cause abscesses and scarring. The reason why hidradenitis suppurativa occurs is unknown. It is essential to identify and diagnose the lesion in its early phases and prevent it from getting worse. In the initial stages, it can be treated with medications. When the condition becomes severe, surgery may be required. A single treatment cannot cure hidradenitis suppurativa. People with hidradenitis suppurativa mostly require medications and lifestyle changes to manage it.
