The Ins & Outs of Hidradenitis Suppurativa (HS)
What is HS?
Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that has been increasingly recognized by not only the dermatologic community, but the community at large as a growing concern. The psychosocial impact and prejudice created overtime among those individuals with hidradenitis suppurativa has empowered dermatologists to advocate and understand the disease process.
What does HS look like?
Hidradenitis suppurativa (HS) is characterized by painful, draining and swollen boils and cysts in the groin, axillae (armpits) and breast regions.
What causes HS?
HS is caused by a blockage of the hair follicle which leads to inflammation in the skin, specifically harboring around the sebaceous glands, the oil producing glands of the skin. The blockage of the hair follicles also allows the accumulation of bacteria that normally live on the skin to over-produce which is what causes pus-filled abscesses and draining cysts. The exact underlying cause for the blockage of hair follicles is unknown. However, many believe that both genetics and environmental factors play a role in the development of HS. Weight gain, smoking, emotional and physical stressors, diet are among contributing factors.
Does HS only impact the skin?
No. Since HS is frequently found underneath the breasts and in the groin in females, it is deemed both a dermatologic and gynecologic disease. Many of my patients impacted with groin and breast lesions often voice their anxiety with participating in sexual practices as a result of embarrassment and pain, drainage and discomfort during sexual practices when lesions are active.
What is out there in regards to treatment of HS?
Treatment of HS is frequently dependent on the severity (the clinical stage of disease). Mild cases of HS where no scarring of the skin is present may be managed by a combination of at-home remedies and topical and/or oral antibiotics. As a dermatologist, in all my HS patients, counseling on warm compresses, antibacterial soaps, antiseptics, weight loss, smoking cessation, wearing loose-fitting clothing and anti-inflammatory over-the-counter medications is at times just as important as prescription treatment. Prior to scarring, laser hair treatment may be helpful in the removal of the hair follicles as not only as treatment, but also a preventative measure.
In more severe cases where scarring may be present, draining and pain is poorly controlled with topical and/or oral antibiotics, oral or injectable immunosuppressive medication may be helpful. Initially prescribed fro psoriasis, psoriatic arthritis and chron’s disease, certain biologic medications (i.e. a class of medications that are either available as injections or infusions that suppress a component of the immune system) are increasingly used in the treatment of HS. In 2015, Humira was approved for the treatment of moderate to severe HS.
Oral retinoid treatment (i.e. isotretinoin) may be used in the treatment of HS, especially in those with a history of acne. Isotretinoin functions to reduce the size of the sebaceous gland, the oil producing gland.
In females with groin and breast lesions flaring around their menstrual period, oral spironolactone may be a helpful treatment. Sprionolactone has been used for many years for the treatment of hormonal acne (acne distributed in the lower cheeks, jawline and flares around the menstrual period).
When inflammation is poorly controlled, I may add on oral zinc gluconate which has been shown in studies to help reduce inflammation within 3-6 months in HS patients. I have found that it’s long-term use has been limited by abdominal pain and nausea, the most common side effects.
When scarring is severe and extensive, surgical removal of the lesions and skin grafting of the areas may be helpful. It is important that prior to surgery, inflammation and breakouts are minimized to help ensure the best surgical outcome and avoid recurrence after surgery.
I often counsel my patients that treatment of HS is not a one size fits all approach and that at times, it may feel like a trial and error; however, with a growing number of treatments there is hope for better control of their disease. HS does not only impact the skin, but also has bearing on their personal and professional life.
I encourage my patients to take a more confident, empowered and active role in their skin health by seeking outside resources and advice through the Hidradenitis Suppurativa Awareness Organization, No BS about HS among other online resources.
Discuss with your dermatologist the various treatment options and recommendations for tackling HS.