Hidradenitis suppurativa (HS) is a chronic, relapsing inflammatory disease of hair follicles in intertriginous regions, characterized by painful nodules, abscesses, double-ended comedones, sinus tracts, and scarring. Pathogenesis involves follicular occlusion, dysregulated innate/adaptive immunity (IL-1, TNF, IL-17 axes), microbiome shifts, mechanical stress, and hormonal/metabolic factors. Disease burden is high with pain, drainage, malodor, and psychosocial impact. Management is staged: lifestyle and skin care, antiseptics, antibiotics, intralesional steroids, hormonal therapies, biologics (notably TNF and IL-17 inhibitors), surgery, and adjunct pain/wound care.
Epidemiology
- Prevalence ~0.1–1%; onset in adolescence/early adulthood; female predominance.
- Risk factors: family history (~30–40%), smoking, obesity/metabolic syndrome, mechanical friction.
- Common sites: axillae, groin, perineal, inframammary, buttocks.
Pathophysiology
- Primary event: follicular occlusion and rupture with keratinous/follicular spill triggering inflammation.
- Cytokines: TNF-α, IL-1β, IL-17/23, IL-36; biofilms in sinus tracts.
- Comorbidities: metabolic syndrome, depression, spondyloarthritis, IBD (especially Crohn), PCOS, pilonidal disease.
Clinical Features and Staging
- Lesions: tender deep nodules, abscesses, draining tunnels (sinus tracts), double comedones, rope-like scars.
- Hurley staging:
- I: abscesses without sinus tracts/scarring.
- II: recurrent abscesses with widely separated tracts/scars.
- III: diffuse involvement with interconnected tracts.
- Severity indices: IHS4, HiSCR for clinical response in trials.
Diagnosis and Differential
- Clinical diagnosis: typical lesions, locations, chronicity.
- Rule out: furunculosis, carbuncles, cutaneous Crohn disease, actinomycosis, pilonidal cysts, acne conglobata, Fox-Fordyce disease.
Management
- Lifestyle and skin care
- Smoking cessation; weight management; friction and heat minimization; breathable clothing.
- Antiseptic washes (chlorhexidine, benzoyl peroxide), dilute bleach soaks; avoid aggressive shaving; gentle depilation options.
- Pain control: NSAIDs, acetaminophen; avoid chronic opioids; neuropathic agents for chronic pain; consider pain specialist.
- Medical therapy
- Intralesional triamcinolone for acute nodules.
- Antibiotics:
- Topical clindamycin 1% for mild disease.
- Oral tetracyclines (doxycycline 100 mg bid) for 8–12 weeks; macrolides as alternatives.
- Combination clindamycin 300 mg bid + rifampin 300 mg bid for 8–12 weeks in moderate disease; monitor LFTs/interactions.
- Moxifloxacin + metronidazole + rifampin regimens for refractory disease (specialist oversight).
- Hormonal therapy (female patients):
- Combined OCPs, spironolactone (50–200 mg/day), finasteride; consider PCOS evaluation.
- Biologics and targeted agents:
- Adalimumab: only FDA/EMA-approved biologic for HS; weekly dosing; aim for HiSCR response.
- Infliximab off-label for severe HS, especially with IBD overlap.
- IL-17A inhibitors: secukinumab approved in many regions (2023–2025) for moderate–severe HS; ixekizumab under study/used off-label.
- IL-1 pathway (anakinra), IL-23 inhibitors (guselkumab, risankizumab) show promise in refractory cases.
- JAK inhibitors under investigation.
- Short oral corticosteroids for acute severe flares; avoid long-term monotherapy.
- Procedures and surgery
- Incision and drainage for fluctuant abscesses (temporizing; recurrence common).
- Deroofing of sinus tracts for localized tunnels (effective and tissue-sparing).
- Wide local excision with secondary intention or grafts/flaps for Hurley II–III disease; combine with perioperative biologic therapy for best outcomes.
- Laser hair removal (Nd:YAG) can reduce flares in selected sites; CO2 laser excision/deroofing options.
- Multidisciplinary and supportive care
- Wound care (absorbent dressings, negative pressure for large defects).
- Psychological support, depression screening; social work for work accommodations.
- Screen/treat comorbidities: IBD, spondyloarthritis, metabolic syndrome.
Prognosis
- Chronic relapsing course; earlier intervention can prevent tunneling/scarring.
- Combined medical-surgical strategies improve long-term control.
References (recent guidelines and key reviews)
- North American HS Guidelines (AAD/HS Foundation), 2022–2024 updates.
- European S1/S2k HS guidelines, 2023–2024.
- RCTs and real-world studies for adalimumab, secukinumab, and surgical outcomes, 2021–2025.