Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic, painful skin condition which is thought to be related to a genetic weakness in the wall of hair follicles in the skin. It often presents with blackheads, pimples, boils, abscesses, scars and tunnels in the armpits, underneath the breasts, groin, inner thighs and/or buttocks. Occasionally, HS lesions can appear on the abdomen, the back of the neck, the chest, the back and behind the ears.

There are four main processes involved in the formation of HS lesions:

1. Abnormal structure of skin cells that line the hair follicles causes oil and dead skin cells to build up in the hair follicle. The hair follicle is weaker than normal and more prone to rupturing.
2. Hormonal influence as increased oil production increases clogging of the hair follicles.
3. Buildup of oil and dead skin cells causes rupturing of the hair follicle, and this leads to inflammation of the surrounding skin, which causes boils.
4. Over time, inflammation can cause tunneling of skin that extends past the initial boil. This can lead to scarring and development of sinus tracts (tunnels that form underneath the skin), which can drain fluid.

The exact cause of HS is not known, and many biological and environmental factors may play a role in its development.

Genetics: An estimated one out of three patients with HS have a family history of the condition.

Lifestyle habits: HS is also more often associated with obesity and smoking cigarettes.

Age: HS commonly occurs in teens and young adults in their early 20s, but can occur at any age.

Sex: Women are three times more likely to develop HS than men.

Other medical conditions: It is not uncommon for patients with HS to have other medical conditions or be at risk of having other diseases, such as inflammatory bowel disease, arthritis, depression, and metabolic syndrome (including high cholesterol, high blood pressure, diabetes and overall higher cardiovascular risk).

Friction and sweating: Exercise and sweating may cause a flare. Clothing that you wear when you exercise may also contribute by chafing against your skin and aggravating HS.

Weather: Some people with HS find that their disease is worse in hot, humid summer weather.

Clothing: If clothing does not breathe and is tight fitting, it might make your HS worse. Try to wear clothing that fits loosely and does not sit against the creases in your skin.

Weight gain: Patients with higher body mass index are more likely to have HS. It has been shown that weight loss improves HS and helps HS management.

Alcohol intake: Some people with HS find that alcohol promotes a flare of their disease.

Smoking: Smoking may trigger a HS flare through different mechanisms.

Physical injury: Either friction or chronic trauma can be a trigger for HS.

Menstrual cycle: Some women with HS have observed a relationship between an HS flare and having their period. Some have also found that their HS symptoms are worse when they are about to menstruate.

Changes in medication usage: A flare of HS may result from a change in or stopping medication. This has been reported particularly with hormonal medications. If a change in your medication results in a flare, it is a good idea to consult with your certified dermatologist.

Stress and emotional distress: Stress may produce a flare of your disease, so managing stress is important for prevention.

HS can have a negative impact on a person’s quality of life, and many people avoid social interaction because they fear being embarrassed or stigmatized. Painful sores might affect your sleep, ability to move, or sex life. The visible signs of HS can be upsetting. You may have large lesions on your skin, and sometimes they can produce an unpleasant odour. This can lead to emotional distress and worry, along with the pain these lesions may cause.

It is normal to feel angry and irritable because of your HS symptoms. In fact, depression and anxiety often occur in those with HS. All these challenges can feel daunting.

Remember that your mental and emotional health are important to your overall health. Talk to your friends, family, family doctor and dermatologist for support and resources.

HS can usually be controlled with proper treatment that involves a combination of medical and surgical therapies. You may need multiple treatments to improve your HS.

General Measures

• Wear loose-fitting, moisture-wicking, absorbent fabrics.
• Avoid picking/squeezing/rubbing the lesions, as this can cause them to become bigger.
• Consider weight loss strategies if you have a higher body mass index, as this can reduce skin-to-skin friction in the areas where you have HS.
• Quit smoking (resources available at: www.quitsmoking.ca).
• Adopt a low glycemic index (low sugar/refined carbohydrate diet), avoid skim milk products (other dairy products are okay) and avoid protein shakes that contain whey or casein protein.

Medical, Surgical and Laser Treatment

• Topical Antibiotics: Clindamycin is a topical antibiotic that can applied to affected areas.
• Topical Resorcinol (15% cream): This is a topical cream that needs to be filled at a compounding pharmacy. This cream helps to reduce plugging of hair follicles and can help treat active HS lesions. We recommend using this daily for 12 weeks to help resolve current lesions (as tolerated, as this medication can cause skin peeling) and when you have an HS flare-up of a current or new lesion.
• Zinc Supplement: 100 mg oral zinc supplement once a day for 3-4 months. This has been shown to reduce inflammatory lesions in HS patients. Zinc competes with copper for absorption in the gut and copper deficiency may lead to anemia. Therefore, you should take a 4 mg copper supplement every day, at a different time of day than when you take the zinc supplement.
• Hormonal Therapies: Reduces plugging of the hair follicles by blocking the activity of androgen hormones.
  • For female patients, we may recommend an oral contraceptive pill that contains drospirenone or cyproterone acetate, as these have anti-androgen activity. These pills are not recommended if you experience migraine headaches with aura, if you smoke tobacco products and are over the age of 35, or if you have ever had a blood clot in the leg (deep vein thrombosis(DVT)) or in the lungs (pulmonary embolism(PE)).
  • Alternatively, spironolactone is another anti-androgenic oral medication that can be used to treat HS. If you have low blood pressure, this may not be the best treatment for you as spironolactone may slightly lower your blood pressure. This treatment is not recommended if you have severe kidney disease or if you are trying to become pregnant, as it can cause feminization of a male fetus.
  • Metformin: This medication is used to improve insulin sensitivity in people with diabetes. Insulin is a hormone that regulates blood sugar levels. People with type 2 diabetes develop insulin resistance, which is characterized by high insulin levels, as the body is unable to effectively use insulin to regulate blood sugar. Metformin helps the body to use insulin more effectively. Metformin has been used successfully to improve HS, as it can help to reduce the levels of androgens from excess insulin levels.
• Oral Antibiotics: HS is not an infectious or a contagious condition, but certain antibiotics have anti-inflammatory effects and can be used to treat HS. Minocycline and doxycycline are commonly prescribed antibiotics that are typically taken daily for three months.
• Biologics: Adalimumab is the only biologic medications that is approved by the FDA to treat HS. This treatment is given as an injection and it is an anti-inflammatory medication that blocks production of TNF-α, which contributes to the inflammation in HS lesions. Biologics are reserved for patients with moderate to severe HS who have not seen improvement of their HS with other treatments. Additionally, clinical trials are ongoing for other biologics. Ask your dermatologist if they know about any ongoing research trials.
• Laser Hair Removal: Laser hair removal selectively targets and destroys hair follicles, which can help prevent new HS lesions from forming in hair-bearing areas of the underarms and pubic area.
• Intralesional Corticosteroid Injections: Corticosteroids can be injected directly into HS lesions to reduce pain and inflammation from flare-ups, and this can help lesions to resolve more quickly. Ask your dermatologist if their office will allow you to book an urgent, fit-in appointment for these injections.
• Botulinum Toxin Injections: Botulinum toxin is used to treat excessive sweating (hyperhidrosis) and although off-label for HS, some studies have found that this can help to reduce the number of HS lesions in treated areas. Some drug insurance plans may cover the cost of this treatment.
• Deroofing Surgery: This is an in-office procedure that is performed under local anesthetic to treat lesions which recur in the same spot or sinus tracts underneath the skin. Deroofing surgery can improve your quality of life by eliminating pain and drainage from problem spots and these lesions often do not come back in the same spot. Ask your dermatologist if you would be a good candidate for deroofing surgery.

If a painful nodule appears, gently applying a wet, warm compress can help reduce swelling and ease pain. Ice packs and over-the-counter options can be effective for mild pain.

Make sure to communicate with your doctor about any pain you are experiencing. Your healthcare team will do what they can to help find a treatment plan that works for you and provide more education on wound care and pain management. Pain can be experienced during a flare-up or chronically.

There is not one common wound care regimen for HS, so be sure to speak to your doctor about the right plan for you. What you use to care for your wounds can vary. Your dermatologist will consider where you have wounds, the amount of leakage, what the skin around each wound looks like, cost, and your preferences. Ideal dressings for HS are inexpensive, absorbent and non-irritating.

Cleaning
Consider using mild soap with water to prevent irritation.

Drainage
Specific dressings may be used for excessive drainage. Absorbent dressings can be worn between your wound and clothing in order to soak up any wound drainage. Advanced dressings may be used in some situations.

Healing
Make sure to maintain a moist wound base (not too wet or dry). It may be necessary to change your dressings more frequently, and wearing loose, breathable clothing is helpful to avoid friction.

1. HS is not an infectious or contagious disease, and it is not caused by poor hygiene.
2. There is a lot of research on new treatments for HS. Your dermatologist is here to help!

Your dermatologist, nurse, pharmacist and other members of your healthcare team are always a great source of information. Additionally, check out these websites for more information:

Canadian Dermatology Association

Canadian Skin Patient Alliance

Canadian Hidradenitis Suppurativa Foundation

HS eBook: An in-depth resource for HS patients that was written by dermatologists who are a part of the national Canadian Hidradenitis Suppurativa Foundation can be found at https://hsfoundation.ca

Support groups

Many people also find it helpful to talk about how they’re feeling with others who are experiencing similar situations. Joining an in-person or online support group can be a great way to learn more about your HS community and pick up tips and tricks that others with the condition use in their daily lives.

Canadian HS patient organizations:

Hidradenitis and Me

HS Heroes