She was brought in by her mother, who experienced the same symptoms. After the exam, we sat down and discussed the diagnosis and treatment options. Tearfully, she told me, “I just want to feel normal.” This interaction really touched me; she had her whole life ahead of her and was worried about the emotional and physical toll this condition was already taking on her. It worried me, too. I wanted to do everything I could to manage her condition and improve her quality of life.
I diagnosed her with hidradenitis suppurativa. Also known as HS, this is a chronic, relapsing condition that occurs within the hair follicle. It is defined as a recurring development of boils or pimples under the breasts or in the underarms, groin, or buttocks. The scalp and behind the ears are rarely involved.
Women are three times more likely to be affected than men. There is a strong genetic association, with 30%-40% of women reporting a first-degree relative with a history of HS, with a strong predisposition toward women of African descent.
People with HS are more likely to deal with other conditions, like obesity, metabolic syndrome, polycystic ovary syndrome (PCOS), depression, and anxiety, to name a few. Recent studies have also shown a strong association between obesity and symptom severity of HS.
For some, weight loss of at least 15% can significantly improve HS symptoms. Weight loss can be a tough feat for HS patients. Inflammation can make it physically difficult to lose weight, so I try to be tactful when discussing weight loss with HS patients.
Hidradenitis suppurativa is a clinical diagnosis, and severity is classified by a system known as Hurley staging.
Hurley Staging System
Hurley I: Single or multiple abscesses without sinus tract formation
Hurley II: Recurring abscesses with sinus tract formation and scarring
Hurley III: Diffuse abscesses and interconnecting tract formation
This classification system determines severity by the presence or absence of scarring and sinus tracts. Sinus tracts are tunnels created within the skin as a result of chronic and recurring inflammation. This is considered the most reliable classification system in grading HS severity. It is also a helpful tool for your doctor to choose the most appropriate treatment.
- Tobacco use
- Tight clothing
- Weight gain
- Excessive heat
- Sweating
HS treatment consists of symptom control and maintenance therapy. To control pain, I recommend topical lidocaine or oral analgesics like ibuprofen or acetaminophen.
For an active flare, I recommend topical or injectable steroids to help with immediate inflammation. Steroid injections are shown to reduce inflammation and redness after 24 hours. This can be repeated every 4-6 weeks if the flares are predictable and coincide with your menstrual cycle.
Antibiotics are another useful treatment. In both oral and topical formulations, antibiotics provide a useful tool for flares and maintenance treatment. One study showed reduced pain and improved quality of life scores with both oral doxycycline or clindamycin and rifampin combination therapy. Antibiotic treatment is typically prescribed in cycles to avoid antibiotic resistance.
Newer treatments, like biologic therapy, offer a more targeted treatment for HS patients. These FDA-approved biologic therapies include a class of drugs called secukinumab and adalimumab. They work to block proteins that cause swelling and inflammation in your body.
