Hidradenitis Suppurativa is a chronic, inflammatory skin condition characterized by recurring, boil-like abscesses. These lesions often lead to purulent discharge, slow-healing wounds, and the formation of scar tissue in advanced stages. The condition typically occurs in areas with apocrine sweat glands, such as the groin, under the armpits, or under the breasts. It is also known by the name «Acné Inversa.».
Causes and Risk Factors of Hidradenitis Suppurativa
The etiological connections of Hidradenitis Suppurativa are not yet fully understood. It is believed that the condition begins with follicular occlusion—a blockage of the hair follicles that hinders the function of the apocrine glands. This blockage leads to localized inflammation. In the further course, the surrounding tissue can rupture, bacterial infections can occur, and fistulous tracts can form under the skin, resulting in the characteristic interconnected abscesses.
The following factors are discussed as possible contributing causes:
- Genetic Predisposition: There are frequent reports of cases of Hidradenitis Suppurativa within the same family.
- Sex Hormones: The activity of the apocrine sweat glands is stimulated by androgens and inhibited by estrogens. The exact role of these hormonal influences is the subject of current research.
- Endocrine Factors: Obesity, hirsutism (excessive, male-pattern hair growth in women), and acne occur more frequently in women with Hidradenitis Suppurativa.
- Nicotine Consumption: Smoking appears to increase the incidence of the disease.
Women are affected about three times more often than men, although the actual reasons for this are unknown. Onset usually occurs between the ages of 20 and 40 and correlates with the post-pubertal rise in androgen levels. The disease occurs less frequently after menopause or before puberty.
In some patients, Hidradenitis Suppurativa is part of the follicular occlusion syndrome, which may also include Acne Conglobata, chronic scalp folliculitis, and/or pilonidal sinuses.
Symptomatology: Signs and Stages of Hidradenitis Suppurativa
The severity and appearance of the condition vary considerably among affected individuals. Initially, a firm, pea-sized nodule often forms, similar to a deep-seated acne nodule, with a diameter of about 0.5 to 1.5 cm. These lesions may rupture spontaneously or drain in purulent discharge within a few hours to days. Although they can heal without treatment, new abscesses frequently form later in adjacent areas. If left uncontrolled, larger lumps (up to the size of a golf ball) can develop, fistulous tracts can form, and the affected zone can expand widely.
Three clinical stages are distinguished for the classification of the condition:
- Stage I: Single or multiple isolated abscesses, without significant scarring or fistulous tracts.
- Stage II: Recurrent abscesses that occur singly or in clearly separated areas, accompanied by the formation of fistulous tracts.
- Stage III: Extensively affected regions, characterized by numerous interconnected fistula systems and abscesses.
The spread of the disease can also affect less typical body sites, including the neck, waist, and inner thighs. The anogenital location typically includes the groin, mons pubis, vulva, sides of the scrotum, perineum, buttocks, and perianal folds. The abscesses and fistulous tracts are often associated with considerable pain.
Therapeutic Management of Hidradenitis Suppurativa
Medical treatment for hidradenitis suppurativa presents considerable challenges. The primary goal is to achieve an early diagnosis and apply therapies that control the milder forms of the disease. For all patients, weight loss in cases of overweight and complete cessation of smoking are strongly recommended.
General Measures and Lifestyle Changes
Non-pharmacological actions play a crucial role in managing this chronic condition. These include:
- Washing with antiseptics or anti-acne preparations to reduce the proliferation of commensal bacteria. Solutions of hydrogen peroxide and medical-grade honey have proven useful.
- Wearing loose clothing and avoiding tight garments to minimize direct friction over the affected areas.
- Implementing a low glycemic index diet (which minimizes rapid spikes in blood sugar) and striving to achieve a healthy body weight.
- Strictly abstaining from smoking.
Pharmacological Treatment Options
Medical intervention encompasses various strategies, from topical treatments to advanced systemic therapies:
- Topical anti-acne antibiotics, such as Clindamycin, applied to the affected areas, generally in combination with benzoyl peroxide.
- Short-spectrum oral antibiotic treatments upon the appearance of acute abscesses (painful, hot, and potentially suppurating), usually indicated for staphylococcal infections. Flucloxacillin or Dicloxacillin are primary options, except in cases of penicillin allergy.
- Prolonged administration (minimum 3 months) of Tetracycline or Metronidazole due to their inherent anti-inflammatory effects.
- The combination regimen of Clindamycin and Rifampicin administered for three months may constitute the most effective medical treatment in severe cases.
- The administration of oral contraceptives for 12 months or more can be attempted, typically those containing low estrogen and Cyproterone Acetate (such as Diane-35 or Estelle 35). The anti-androgenic diuretic Spironolactone may also offer benefits.
- Retinoids (Vitamin A derivatives), especially Isotretinoin, known for its efficacy against acne, may be beneficial for hidradenitis suppurativa over a period of 6 to 12 months.
- Systemic or intralesional corticosteroid injections (directly into the nodule) are used to mitigate severe inflammation of the abscesses.
- In the most severe cases, it is crucial to consider the use of biological modulators, such as TNF antagonists, TNF, including Infliximab, Etanercept, and other biological agents.
Surgical Approaches
When conservative treatments are insufficient, surgery offers solutions for managing flares and chronic lesions:
- Incision and drainage of abscesses, especially when pain is predominant or immediate relief is required.
- Persistent hidradenitis plaques may require surgical excision after several months of conservative management (observation and/or antibiotics).
- Complete operative resection is reserved for the most extremely severe forms of the disease.
- Experimentally, Laser-Cryotherapy may be considered useful in certain clinical situations.
- Carbon dioxide laser treatment is a relatively novel method for hidradenitis suppurativa, suitable for mild to moderate cases and does not require hospitalization.
The successful management of hidradenitis suppurativa requires a multidisciplinary approach, combining lifestyle changes, optimized pharmacological therapy, and, when necessary, precise surgical interventions.
