Hidradenitis Suppurativa (HS)

HS is a chronic, relapsing inflammatory disorder of the hair follicle, primarily affecting the skin folds where apocrine glands are located. It typically starts after puberty, peaking between the ages of 21 and 29.

Symptoms:

The dominant symptom is painful lumps or recurrent "boils" that flare, drain, and leave scars. Patients often report:

• Foul odor from draining tunnels.

• Prodromal symptoms (burning, stinging, itching) 12–48 hours before a lesion appears.

• Systemic complaints like fatigue, joint pain, and significant psychological distress.

Strong Associated Factors & Triggers:

• Smoking (strongest environmental link).

• Obesity and Metabolic Syndrome/Diabetes.

• Hormonal fluctuations (e.g., PCOS, menstrual flares).

• Friction, heat, tight clothing, and stress.

• Family history is common.

Crucial Note for Darker Skin Tones:

HS is more common in Black individuals. Under-recognition is frequent because visible redness (erythema) is reduced, leading to diagnostic delays.

HS lesions are found in classic intertriginous (skin fold) areas: Axillae, groin/inguinal folds, perianal/perineal region, and inframammary folds.

Lesion Morphology:

• • • Primary Lesions: Deep-seated, painful nodules and abscesses with purulent, often malodorous drainage.

    • Pathognomonic: Interconnecting sinus tracts (tunnels) beneath the skin.

    • Other: Double-open comedones (a distinctive finding), firm papules, and pseudocysts.

    • Chronic Changes: Thick, fibrotic plaques, rope-like scarring, architectural distortion, and significant Post-inflammatory Hyperpigmentation (PIH).

Key Examination Nuances in Darker Skin Tones:

• • • Color: Lesions appear brown, purple, or grey instead of red. Palpate for warmth and tenderness since erythema is subtle.

    • Sequelae: PIH is prominent and persistent. There is a higher risk of keloid and hypertrophic scarring, which can cause significant architectural distortion.

Severity Assessment (Hurley Staging):

• • • Stage I (Mild): Isolated nodules; NO sinus tracts or scarring.

    • Stage II (Moderate): Recurrent abscesses; presence of sinus tracts and scarring.

    • Stage III (Severe): Diffuse, interconnected tracts and abscesses across a wide area.

Management of HS is challenging, focusing on controlling inflammation, preventing new lesions, and addressing associated risk factors and psychosocial distress.

1. General Measures and Lifestyle Modification:

• Cessation: Smoking cessation is mandatory.

• Weight Management: Weight reduction (metformin or GLP-1 agonists may assist in obese/diabetic patients).

• Avoid Friction: Advise against tight clothing, shaving affected areas, and harsh cleansers/deodorants.

• Hygiene: Use topical antibacterial washes (Chlorhexidine, Benzoyl Peroxide).

• Pain & Psycho-Social: Use NSAIDs for acute pain and ensure patients receive psychological support for high rates of depression and anxiety.

2. Medical Therapy (Based on Severity):

See Hurley Staging below

3. Biologic Therapy (Systemic Biologics):

• Indicated for moderate-to-severe disease that has failed systemic antibiotics.

• Adalimumab (anti-TNF) is often the first-line biologic choice. Secukinumab and Bimekizumab are newer IL-17 inhibitors.

4. Procedural / Surgical:

• Deroofing (Unroofing): Preferred for treating established, chronic sinus tracts.

• Wide Local Excision: Definitive option for severe, localized, Hurley III disease.

• Avoid routine Incision and Drainage (I&D), as it has a nearly 100% recurrence rate.

Darker Skin Tones – Specific Management:

• Scarring: Minimize unnecessary trauma (e.g., aggressive I&D) to reduce the risk of keloid and hypertrophic scars.

• PIH: Treat post-inflammatory hyperpigmentation after the inflammation subsides with sun protection and topical agents like azelaic acid.

Skinsight – Hidradenitis Suppurativa: https://skinsight.com/resource-center/hidradenitis-suppurativa/

NCBI Bookshelf / StatPearls – Hidradenitis Suppurativa: https://www.ncbi.nlm.nih.gov/books/NBK534867/

DermNet NZ – Hidradenitis Suppurativa: https://dermnetnz.org/topics/hidradenitis-suppurativa