Symptoms and causes

Hidradenitis suppurativa (HS), also known as Acne inversa or Verneuil's disease, is an inflammatory disease that occurs in the skin folds.

Literally translated, HS means an inflammation of the sweat glands resulting suppuration. This name is not entirely correct because it actually concerns a chronic condition in which inflammation forms around the hair follicles in places with a lot of sweat glands and hairs, but also in places where there is a lot of friction, such as in skin folds. Usually the disease develops in the armpits, in the groin, on the buttocks, both between and under the breasts, but also in other places.

Cause

The cause of HS is a blockage of a hair follicle due to an increased hardening of the skin at the exit of the hair follicle on the one hand and an increase in the cells in the wall of the hair follicle on the other. As a result, skin cells and sebum accumulate in the hair follicle, which eventually overfills. As a result, this hair follicle will burst subcutaneously, causing an inflammatory reaction.

The causes of the clogging of the hair follicle are not yet fully known. This is probably a combination of various factors such as heredity, disruption of the immune system, hormones, age, gender, smoking and obesity.

It affects about 1% of Europeans, so it is not so rare. It is more common among women than men. It can occur at any age, but we usually see it for the first time in young adults. Overweight individuals and smokers are affected significantly more often.

Typical lesions for HS

The inflammation can occur in the form of red, painful nodules in or under the skin, which we call 'inflammatory nodules'. Sometimes these can evolve into an abscess, this is an accumulation of pus in the tissue. Fistulae may also be present. These are tunnels that can make a connection between deep inflammations and the skin surface, but also between deep inflammations themselves. From these fistulae, a pushy secretion can be observed. We also see double-ended blackheads or comedones. More advanced conditions can result in hard scars and entire zones of scarring. Most of these inflammations are painful.

Diagnosis and treatment

The diagnosis can be made based on a physical examination. There are three conditions that have to be met in order to be able to speak of HS:

  1. there must be typical lesions
  2. these lesions must occur at the typical locations
  3. During a period of six months, we expect at least two episodes

Different forms of HS have been described, we call these the Hurley stages. These stages are determined based on the extensiveness and type of the lesions.

Lifestyle changes are certainly important in the treatment of HS. Smoking can play a role in the development of HS and for this reason, quitting smoking is very important. Being overweight also leads to chronic inflammation in the body and can lead to more friction in the skin folds. The increased friction causes more clogging of the hair follicles. Patients who are overweight should therefore lose weight. To reduce friction, it is also advisable to wear loose-fitting clothing as much as possible.

Washing with disinfectant soaps is recommended to avoid additional infections. These soaps can cause irritation if used too frequently, so we recommend using them only two to three times a week. Skin irritation should be avoided.

In addition to lifestyle changes, there are also various medical and surgical treatments available. Depending on the symptoms and extensiveness, the physician will discuss the different treatment options with the patient.

Most forms of treatment

For mild forms, an antibiotic ointment or lotion treatment can be chosen that will be applied to the skin lesions for a few weeks to several months. These reduce the inflammation.

If there are many double-ended blackheads, a resorcine-based ointment can be prescribed for daily use in mild forms. Resorcine helps to solve the blockage.

In the event of an acute excerbation of a lump, it can be injected with a cortisone medicinal product to stop the inflammation. An abscess can be incised to free up pressing pus.

Inflammatory antibiotics in pill form (minocycline, lymecycline) are often used to inhibit the inflammation of HS. These are usually prescribed for a few months. Either a single antibiotic or a combination of several antibiotics together can be chosen, depending on the severity.

In moderate to severe forms of HS in which all other medication gives insufficient results, a patient may qualify for a biological solution. These are modern medications that specifically inhibit inflammation in order to control the condition.

In combination with medication, surgical treatment is also often performed.

After all, the disease causes permanent scar structures that can subsequently become repeatedly inflamed. There are roughly two different methods of surgical treatment:

  • 'deroofing': (literally 'removing the roof'): removing the top skin layer over a fistula or sinus, after which the wound heals by growing closed.
  • broad removal: removal fof the entire affected scar structure after which the surgical wound can either be closed or grow closed with ointments and bandages.

Why are wounds not always sutured up?

In HS, it is not always easy to estimate the exact edges of the lesions. If a small remainder of the inflammatory site or scar structure were to remain, it could get inflamed again and expand after healing. This is more likely to happen when the surgical wound is closed with sutures, because the rest can be 'sutured in', as it were. When growing closed, scar tissue is gradually replaced and any remnants disappear, although even with this technique, a relapse cannot be ruled out 100%.

For this reason, healing with 'self-closing' is often chosen.

Can the disease be cured?

At the moment, there is not a definitive cure. The condition has multiple causes (genetic, immune system, lifestyle) which can cause new outbreaks later in life. Often, a correct combination of medication and/or operations can result in long-term disease control (remission).

Treatment centres and specialisations

Dermatology

Latest publication date: 21/01/2021
Supervising author: Dr Van Autryve Els