Hidradenitis suppurativa (HS) is when recurring inflamed nodules (small, solid lump) and cysts (fluid-filled mass) appear in the armpits and groin. These lesions may also be found under the breasts and even around the nipples and anus.

The lesions start as plugged pores in the sweat and oil glands. The plugging allows material to build up under the skin. The body's inflammatory system attacks these materials, causing nodules and cysts to form. These lesions can rupture under the skin and form large, painful abscesses; while on the skin's surface, they can form draining sinuses.

The affected areas may have a bad smell, and may eventually heal and leave scars. Because HS worsens with time, it is important to treat this condition as early as possible. Having another infection in these lesions is rare, and when it occurs, the bacterium that is almost always present is Staphylococcus aureus—'staph' for short. But, hidradenitis suppurativa is different from true staph infections that cause unrelated conditions such as carbuncles, furuncles, folliculitis, boils, and staph infections of skin glands blocked by acne. Pilonidal cysts may be seen with HS, but may also occur alone.

Causes

Hidradenitis suppurativa is caused when a duct (a channel that carries gland or organ secretions) in the body is blocked. Material traveling in the duct becomes backed up and infected. The sweat and oil glands located in areas where skin folds over on itself, such as the armpits and groin, can become plugged. When this happens, oil, sweat, and dead skin cells build up. Skin bacteria may invade and produce an infection.

Risk Factors

The following factors increase your chances of developing hidradenitis suppurativa. If you have any of these risk factors, tell your doctor:

• Genetics: Although there is little that can be done to treat genetic disease, it is important to know that this is a major part of the problem. Doctors are still determining what the genetic defect(s) might be.

• Antperspirants: Some think that aluminum-containing antiperspirants are a risk factor. But researchers are still uncertain whether this is a risk factor because many patients with HS have it in areas never exposed to antiperspirants.

• Obesity, alone or with polycystic ovarian syndrome (PCOS), insulin resistance, or syndrome X.

• Androgen dysfunction (excess male hormone)

• Crohn’s and other inflammatory autoimmune conditions

• Anemia hyperhidrosis (excess sweat production)

• Acne

• Medications: Lithium and some oral contraceptives may make the problem worse.

• Smoking interferes with healing, making the lesions resistant to therapy.

Symptoms

If you experience these symptoms, see your physician soon, before the infection spreads. Symptoms include:

• Painful swellings in the armpits, groin, under the breasts, around the nipples, or around the anus.

• Pus leaking from openings in the swellings

• Foul smell from the affected areas

• Scarring

• Depression and social isolation may also occur

If you experience any of these symptoms due not assume it is due to hidradenitis suppurativa. These symptoms may be caused by other, less serious health conditions. If you experience any one of them, see your doctor.

Diagnosis

Your doctor will ask about your symptoms and medical history, and perform a physical exam. This exam should include every crease and fold on your body that might be affected by HS. Tell the doctor about every sore lump you have, some are not visible but you will know where they are.

Your doctor may refer you to a dermatologist or, if the disease is extensive, a dermatological, plastic, general, or gynecological surgeon may be consulted. The important thing is to find a surgeon with experience in treating the abscesses and sinuses.

Tests may include:

• Culture of the drainage to identify the bacteria

Treatment

Talk with your doctor about the best treatment plan for you. Treatment options vary, are not always effective, and include the following:

Hot Packs: Heat is thought to ‘draw out’ an infection, causing drainage to the surface rather than allowing it to spread under the skin. This treatment is uncertain, but repeated warm baths may be used instead of heat packs because they are soothing and may soften the skin surface, allowing abscesses to drain.

Antibiotics: Long-term use of oral and topical anti-inflammatory antibiotics such as those used in cases of severe acne, may stop inflammation. But be aware that long-term use of antibiotics can gradually produce resistant bacteria and secondary yeast infections.

Cortisone: Cortisone-like drugs, taken either orally for a few days or injected into the lesions, have proven effective for short-term treatment, but should be avoided over the long-term because of slow healing, spreading of infections, and other side effects.

Male Hormone (Androgen) Suppression: Because the affected glands are in hormone-sensitive areas, managing hormonal abnormality is important. This means using appropriate birth control pills and hormone blockers and not consuming dairy (contains hormones) for at least a year. The hormone blockers include cyproterone acetate, which is not available in the US, but is used elsewhere either alone or combined with ethinyl estradiol. It can suppress acne in women and has improved hidradenitis suppurativa. Other anti-androgens include drospirenone (available as a birth control pill), flutamide, finasteride, dutasteride, and spironolactone.

Surgery: Individual nodules, cysts, and sinuses can be treated in the doctor's office with 'unroofing' procedures. Several visits may be needed to control the numerous areas involved. If the involvement is more severe, then wide excision of the affected area—removing all involved cysts, nodules, and connecting sinuses might be done as a last resort. The wounds are left open after all the offending glands and sinus tracts are removed to allow healing. The surgical site, if very large, may be covered with a skin graft.

Laser Excision: Carbon dioxide laser excision has the same result as surgery.

Prevention

To help reduce your chances of getting hidradenitis suppurativa, or getting more lesions, take the following steps:

• Don't smoke. If you smoke, quit. Nicotine patches or gum will not block healing the way inhaled smoke can.

• Achieve and maintain a normal body weight.

• Avoid antiperspirants that contain aluminum if the lesions are under the arms; deodorants are permitted.

• There is a possibility that the hormones in milk and other dairy foods may worsen HS, so consider avoiding dairy products. If you also have acne, not consuming dairy products might improve it as well.

RESOURCES:

American Osteopathic College of Dermatology
http://www.aocd.org

Hidradenitis Suppurativa Foundation, Inc.
http://www.hs-foundation.org

Johns Hopkins University Dermatology Image Atlas
http://dermatlas.med.jhmi.edu

CANADIAN RESOURCES:

BC Health Guide, British Columbia Ministry of Health
http://www.bchealthguide.org

References:

British Association of Dermatologists. Patient Information http://www.bad.org.uk/public/leaflets/bad_patient_information_gateway_leaflets/hidradenitis/index.asp

Hidradenitis Suppurativa Foundation, Inc website. Available at: http://www.hs-foundation.org/.

HS-USA website. Available at: http://hs-usa.org/hidradenitis_suppurativa.htm. Accessed August 11, 2005.

The Merck Manual, 17th ed. West Point, PA: Merck and Co; 1999.

National Organization of Rare Diseases http://www.rarediseases.org/search/rdbdetail_abstract.html?disname=Hidradenitis%20Suppurativa.

The no milk acne diet. The Acne and Milk website. Available at: http://www.acnemilk.com/the_no_milk_acne_diet.

Pictures of HS. Dermis, University of Erlangen, Germany website. Available at: http://www3.dermis.net/dermisroot/en/36184/diagnose.htm.