Not Your Typical Boils and Not Your Fault

What is Hidradenitis Suppurativa?

Hidradenitis suppurativa (HS) is a genetically inherited chronic (long-term) inflammatory skin condition that causes recurrent painful bumps most often in skin folds.  The bumps frequently drain white discharge and cause tracts to form under the skin which can often lead to severe scarring.   Although bacteria is involved in the inflammation that occurs under the skin in HS, HS is not an infection and is often confused by many in the health care field as typical boils.  Here is the difference:

Boil

Unlike HS, a boil (also known as a furuncle) is a true infection of the hair follicle that is usually caused by staph bacteria.  Boils are painful, red swollen areas of skin that drain yellow pus and can occur anywhere on the skin.  They can be cured with draining the areas and/or taking short courses of antibiotics.  It is uncommon to have recurrent boils, unless you have a resistant strain of bacteria.  Boils also usually do not cause scarring.

Hidradenitis SuppurativaI

On the other hand, HS is not caused by bacteria and although it can sometimes be helpful in improving symptoms, draining the bumps and giving antibiotics does not cure this condition.  In addition, the skin bumps of HS are recurrent and often appear in areas where skin rubs on skin: under the arms, under the breasts, folds of the belly, between the thighs and buttocks.  Finally, HS causes scarring in areas where skin bumps appear.

What causes Hidradenitis Suppurativa?

The cause of HS is unknown but it is likely a combination of genetic and environmental factors.  It is well documented in studies that HS may run in families.  Having treated many patients with HS, I have found this to be true more often than not.  Many patients with HS sometimes think that their skin condition is being caused by something they are doing, but this is not true.  I am here to shed some light on these untruths:

  • HS is not caused by what you eat
  • HS is not caused by being dirty or unclean
  • HS is not caused by stress
  • HS is not contagious

Here is what doctors and scientists actually know about the root cause of HS: We know that patients who have HS have defective hair follicles in areas where special sweat glands, called apocrine glands, are found (i.e. in the armpits, groin, etc.).  The lining of these hair follicles is abnormal and leads to the hair follicles getting plugged/clogged (known as follicular occlusion).  Blocked hair follicles trap bacteria under the skin which then leads to inflammation (painful skin bumps) and sometimes rupture of the hair follicle (drainage, tract formation, and scarring).  In some patients with HS, abnormal hormone levels of androgens (hormone that converts to testosterone) is also thought to play a role in blocking hair follicles.

How is it treated?

Currently there is no cure for HS, however, there are many treatment options that can improve symptoms and keep outbreaks well controlled.

Targeting blocked hair follicles:

Benzoyl peroxide is a common ingredient in many acne creams and washes.  The way that it helps in acne is by unclogging “pores”, decreasing inflammation, and killing the bacteria that worsens acne.  Similarly, it can be used to help “unblock” hair follicles in patients with HS as well as help with inflammation.  I recommend using a 10% benzoyl peroxide wash (examples include Panoxyl and Clean and Clear Continuous Control) once to twice daily for all of my patients with HS.  There are topical and oral medications derived from Vitamin A that may improve symptoms of HS because of their known effect on the lining of hair follicles.  There have also been studies that show that treatment with certain lasers can be helpful in destroying the abnormal hair follicles, which improves symptoms and flares in many.

Targeting bacteria:

As discussed earlier, bacteria is not the cause of HS but overgrowth of bacteria due to blocked hair follicles can lead to inflammation and worsening symptoms.  Treating bacteria with oral, topical and sometimes IV antibiotics can be very helpful in improving symptoms of HS, especially during a bad flare up.  Sometimes antibacterial washes and diluted bleach baths are also recommended for patients with HS in order to keep bacteria counts on the skin to a minimum.

Targeting inflammation:

Inflammation (the swelling, pain and drainage caused by immune cells) is a key component in HS.  There are many medications that can be used to reduce inflammation in HS such as antibiotics (topical, oral or IV), steroids, biologics (for example, Humira and Remicade) and other immune suppressants.

Targeting abnormal hormone levels:

There is some evidence that suggests that certain hormones many play a role in HS.  This is especially true in female patients who notice flaring of their condition with their menstrual cycles.  In these cases, medications that are targeted at blocking or lowering these hormone levels can be used to help better control HS symptoms.

Surgical options:

There are many surgical options for patients with HS.  When skin bumps get very large and painful simply opening them up to drain can be helpful in providing relief for many..  When patients with HS begin forming tracts under the skin, these areas are often prone to recurrent flares.  Surgically opening and removing these tracts and allowing the skin to heal from the inside out is a technique often used to get rid of these problem areas.  Finally, for patients who have disease limited to a few areas that are well controlled, surgical excision of the entire area of involvement is an option that could potentially lead to a cure for some people.

What can be done to keep HS symptoms well controlled?

In addition to working with your doctor and sticking to your treatment plan, it’s important to realize that there are steps that patients with HS can take to try to keep there skin under better control.  It has been shown that patients who have HS and are overweight tend to have worse disease than those who are not overweight.  Also, in patients who have HS and loose weight, significant improvement in symptoms has been observed.  Trying to maintain a healthy diet (typically, low carbohydrate/high protein) and exercising regularly in order to be at a optimal weight is very important in controlling HS.  For patients that need help in this realm, working with a nutritionist to meet these goals can be extremely helpful.

Secondly, smoking is a big no no.  Smoking, which has many harmful effects on the body, has specifically been shown to worsen symptoms of HS.  Patients who have HS and smoke tend to have more flares that are more severe and more difficult to control.  Smokers who have HS and successfully quit will often experience improvement in their disease symptoms.  Moral of the story?  If you are a smoker and have HS, it is important to work with your physician in trying to quit.  If you have HS and are not a smoker, don’t start!

Although HS is a condition that affects many and can be quite debilitating if not properly treated, there are many ways to keep this condition well controlled.  If you have HS it’s important to be patient, stay positive and work with your physician to find a treatment plan that works for you.