Hidradenitis Suppurativa and the Challenges of Treatment

The chronic skin condition hidradenitis suppurativa can be complicated for a variety of reasons. For one, the condition can be embarrassing so patients may be reticent to discuss their symptoms until the symptoms are well advanced. Yet early diagnosis and treatment can be key to effectively managing this challenging condition. While some patients may contend with only a mild case, those with more severe cases may ultimately need surgery to remove large areas of skin as well as secondary wound closure.

With symptoms commonly appearing after puberty and into young adulthood, the condition is characterized by recurring painful bumps and abscesses typically in areas that sweat or are exposed to skin-to-skin contact—underarm, groin and buttocks are common locations. Bumps and abscesses can become tunnels, called sinus tracts, under the skin that break though and emit an unpleasant odor.

Hidradenitis suppurativa affects one to two people out of every 100, according to the Hidradenitis Suppurativa Foundation, although certain patient populations experience higher incidence rates. For instance, women are three times more likely than men to develop hidradenitis suppurativa. There may also be a genetic component as upwards of 30% of patients also have a family member with the disease. People who are Black and biracial are also more likely to develop it than Caucasians.

While the exact causes are unknown, the inflammatory disease presents when hair follicles in the skin become blocked and infected, leading to an inflammatory cascade. Patients with hidradenitis suppurativa may spend years or decades with unsightly and painful outbreaks and the chances of recurrence are high.

Here are a few challenges in treating hidradenitis suppurativa patients:

Patients May Be Too Embarrassed to Seek Treatment

Early diagnosis and treatment can help manage symptoms and prevent new lesions from forming, yet the condition often goes undiagnosed for years because patients are too ashamed to talk about their hidradenitis suppurativa symptoms.

Women tend to develop it in the axillary or vulva, while males tend to develop it in the anal region. Hidradenitis suppurativa may also appear in the armpit, groin, scalp and breast area. Heat, humidity, perspiration, weight gain, menstruation, hormone changes and stress may trigger flare-ups. Patients may not only have pain and discomfort but may also suffer psychological problems. They may be embarrassed by the location and odor of the sores, and hesitate to go out in public, leading to social isolation.

Hidradenitis Suppurativa Is a Progressive Disease

Patients typically deal with the condition for many years, although it may improve or worsen at times. Hidradenitis suppurativa stages are defined by Hurley Stages.

• • Hurley Stage I: Early symptoms may include itching and discomfort. There may be one or more areas affected, but they are far apart. At this stage, there is typically no scarring or tunnel-like tracts, called sinus tracts, under the skin.
  • Hurley Stage II: There are recurrent abscesses, with sinus tracts and scar formation. There may be single or multiple widely separated lesions.
  • Hurley stage III: Large areas are affected with multiple interconnected tracts and scars.

There is no cure for hidradenitis suppurativa. Mild cases may be addressed with home remedies such as antibacterial soap, anti-inflammatory medication, antiseptics, and making sure to wear loose-fitting clothing, while more severe cases may require additional treatment from a healthcare professional. Those treatments may include antibiotics, hormones, immunosuppressants and light therapy.

Surgery: Sometimes the Best, Yet Still Imperfect, Treatment Option

Treatment for hidradenitis suppurativa can involve surgery, especially in more advanced cases when other therapies are not effective. It is recommended that patients undergo surgery before the disease becomes too widespread.

Surgical intervention can also address the risk of a rare complication of chronic and severe cases—squamous cell carcinoma (SCC). Research shows a nearly 50% mortality rate for those who develop SCC with hidradenitis suppurativa.

The surgical options for hidradenitis suppurativa may include:

• • Incision and drainage may offer short-term pain relief, but sores often return.
  • Deroofing involves removing the sinus “roof” of the tunnel, exploring and treating the side passages, and wound healing by secondary intention. This may be performed on individual lesions (local unroofing) or for all lesions in an anatomic area (extensive unroofing).
  • STEEP stands for “skin tissue sparing excision and electrosurgical peeling.” It combines excision and the removal of fibrotic tissue.
  • Excision may be recommended for patients with more severe cases. Limited local excision involves removing individual lesions along with a margin of healthy tissue. Local incision helps to control the disease, but often leads to a high recurrence rate in the same area. Wide excision involves removing all lesions in one area, along with skin beyond the clinical borders of disease activity.

While surgery may be the best chance for improvement in severe cases, it is far from foolproof. A study of 42 hidradenitis suppurativa patients who underwent wide excision found that half of patients had a recurrence one year post-surgery and that the average recurrence happened 1.7 years after surgery. Most recurrences were located less than 1 cm from the surgical site.

Obesity, excessive alcohol consumption, and smoking are often considered risk factors for hidradenitis suppurativa, and physicians and surgeons often counsel their symptomatic patients with symptoms to make lifestyle changes. There is no definitive answer about what causes recurrence post-surgery, but patients willing to make lifestyle changes may be more likely to have a positive outcome.

Read 7 interesting takeaways from a comparison of hidradenitis suppurativa treatment guidelines across the globe.