Hidradenitis Suppurativa
A chronic, painful skin condition causing recurring boils and tunnels under the skin, usually in the armpits and groin.
Emergency Management: Severe acute abscess requiring urgent incision and drainage for pain relief.
Hidradenitis suppurativa (HS) is a chronic, autoinflammatory disorder of the terminal hair follicles in intertriginous areas (axillae, groin, perineum), characterized by recurrent painful nodules, abscesses, and sinus tracts.
Detailed Overview
HS begins with follicular hyperkeratosis leading to occlusion and rupture of the pilosebaceous unit. The release of follicular contents into the dermis triggers an intense immune response. Severe pain and purulent drainage severely impact quality of life.
Epidemiology & Demographics
Prevalence is roughly 1%. More common in women (3:1) and usually presents post-puberty.
Etiological Mechanism
Multifactorial: genetic susceptibility, immune dysregulation, and environmental factors.
Primary Causes
Follicular occlusion and autoinflammation
Primary defect is hyperkeratosis of the infundibulum. The follicle occludes, dilates, and ruptures, spilling keratin and bacteria. This triggers a massive innate and adaptive immune response (TNF-alpha, IL-17). Chronic inflammation causes sinus tract formation and hypertrophic scarring.
Diagnostic Criteria & Guidelines
Clinical diagnosis based on typical lesions (nodules/sinuses), typical locations (intertriginous), and chronicity (≥2 relapses in 6 months).
Hurley I: Topical Clindamycin 1% BID. Hurley II: Doxycycline 100 mg PO BID for 12 weeks for anti-inflammatory effect.
Second-Line & Adjunctive Therapy
Adalimumab 160 mg SQ day 1, 80 mg day 15, then 40 mg SQ weekly.
Surgical & Procedural Management
Deroofing of isolated sinus tracts. Wide local excision with grafting for Hurley III.
Patient Counseling & Advice
Explain that it is not contagious and not due to poor hygiene. Emphasize smoking cessation as critical for treatment success.
Follow-Up & Monitoring Schedule
Dermatology follow up every 3 months. Screen for depression (PHQ-9).
Preventive Strategies
Strict avoidance of smoking and weight control to prevent disease progression.
Chronic, relapsing course. Surgical excision of affected areas offers the best chance of local cure.