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Patient Information Leaflet

Hidradenitis suppurativa

What are the aims of this leaflet?

This leaflet has been written to help you understand more about hidradenitis suppurativa. It tells you what it is, what causes it, what can be done about it, and where you can find out more about it.

What is hidradenitis suppurativa?

Hidradenitis suppurativa is a chronic, recurrent, and painful disease that presents with inflammation of a type of sweat glands known as apocrine glands. These glands are found mainly in the armpits and groins. Hidradenitis is also associated with plugging of the hair follicles. This causes the appearance of a mixture of boil-like lumps, areas leaking pus, and scarring.  Hidradenitis tends to begin in the twenties or thirties, and females are more likely to develop it. Recent studies suggest that it can affect nearly 1% of the population.

What causes hidradenitis suppurativa?

It is still not clear why some people get this disease, but mechanical blockage of the pores plays a part. As the secretions cannot escape, the tubes containing them may swell up and burst, or become infected.

Contributory factors include the following:

• Hormones may be involved in the control of apocrine sweat glands and certainly play a part in the disease. Hidradenitis suppurativa affects women more often than men. It does not start before puberty or after the menopause. It may get better during pregnancy, but is often worse before menstrual periods. Some patients do well with hormone treatments (see below). 
  
• Bacteria play a part too, but a variety of germs, and not just one special type, is found in the spots. It is not clear whether they cause the disease, or just flourish within it. 
  
• The immune system is involved in some way with the severity of hidradenitis and treatments that reduce the immune system activity have been used with success in occasional cases (see below).
  
• Hidradenitis could be also linked to the bowel disease called Crohn’s disease especially if it involves the groins and the anus areas.
  
• There may be a link with acne and occasionally pilonidal sinus (a chronic abscess at the base of the spine).
  
• Smoking and obesity are not primary causes of hidradenitis, but are strongly associated with it and may make it worse.
  
• Poor hygiene does not cause hidradenitis suppurativa.

Is hidradenitis suppurativa hereditary?

Hidradenitis suppurativa sometimes runs in families but not always.  

What are the symptoms of hidradenitis suppurativa?

Hidradenitis suppurativa is usually painful, and the lumps hurt if they are pressed. When severe it can have psychological effects or can be associated with inflammation of the joints (arthritis).

The main areas to be affected are the armpits, and the skin of the groin, genital and pubic region. The skin around the anus, on the upper buttocks and thighs, and below the breasts, can give trouble too.

In the affected areas, the skin shows a variable mixture of blackheads, red lumps looking like boils, pus spots, cysts, and areas that constantly leak pus (sinuses). As time goes by, more and more scarring appears.

How will hidradenitis suppurativa be diagnosed?

The diagnosis is made clinically, taking into account the areas that are affected, and the look of the spots. Your doctor may take swabs from the area to see which type of germ is present.

Can hidradenitis suppurativa be cured?

No, it usually persists for many years, but may become inactive eventually. Treatment usually helps even though it cannot switch the hidradenitis off once and for all.
How can hidradenitis suppurativa be treated?

As there is no cure from hidradenitis suppurativa, treatment has to be tailored for each individual. In general terms, early hidradenitis suppurativa is usually treated medically, whereas more chronic and severe hidradenitis suppurativa may need surgery:

If hidradenitis suppurativa suddenly becomes worse:

• This may be due to an infection with ordinary germs of the types that infect cuts and grazes; so antibiotics such as flucloxacillin may be used as a short course. This can be given to you by your GP.
  
• If this fails you might need to go to the casualty department in the nearest hospital to have the abscess/boil treated surgically, followed by an antibiotic.

Suppressive treatment:

• Antibiotics: These are given by mouth. They have to be taken for a prolonged (at least 3 months) course in order to help to suppress attacks. There are different types that can be given with variable outcome for each. These include Flucloxacillin, Erythromycin, Clarithromycin, Tetracycline, Doxycycline, Minocycline, Lymecycline, Metronidazole, Clindamycin and Rifampicin. 
  
• Antiseptics: Patients are frequently prescribed an antiseptic such as 4% chlorhexidine wash, to reduce bacterial colonisation of the skin. Antiseptics are usually applied to all areas of the skin except the head and neck, and are washed off after five minutes.
  
• Retinoids (vitamin A derived tablets) such as isotretinoin or acitretin may help too, but they have to be given with caution, so they are available only from dermatology clinics. 
  
• For women whose hidradenitis suppurativa flares before each period, tablets known as antiandrogens can sometimes be useful. 
  
• Immunosuppressive treatment: If the disease is severe, stronger immune suppressant drugs may be used but with caution as their benefit has to be weighed against their possible side effects. These drugs include tablets or injections. The tablets include oral corticosteroids, ciclosporin, tacrolimus, mycophenolate mofetil, and others. The injections are called collectively ‘biologics’ and include infliximab, etanercept, adalimumab, and others.

Treatment of resistant cases:

• Persistent discharge or infection in the same site usually means that the medical treatments listed above will not work, and surgical operations - either to remove small areas of repeated inflammation, or wider procedures to take away all the diseased glands - are needed in some cases.
  
• Other methods of treatment include cryotherapy (freezing with liquid nitrogen), photodynamic therapy, and ablative laser therapy. None of these are of proven benefit.

Self Care (What can I do?)

• Wash with antiseptic soaps or bath additives
  
• Avoid  tight- clothing
  
• Stop smoking 
  
• Stress management
  
• Support group referral
  
• Lose weight

Where can I get more information about hidradenitis suppurativa?

Web links to detailed leaflets:

http://emedicine.medscape.com/article/1073117-overview
www.dermnetnz.org/dna.hidsup/hidsup.html

The British Skin Foundation fund vital research into all skin diseases. To find out how you can help, please visit the British Skin Foundation website here.

This leaflet aims to provide accurate information about the subject and is a consensus of the views held by representatives of the British Association of Dermatologists: its contents, however, may occasionally differ from the advice given to you by your doctor. 

This leaflet has been assessed for readability by the British Association of Dermatologists’ Patient Information Lay Review Panel

BRITISH ASSOCIATION OF DERMATOLOGISTS
PATIENT INFORMATION LEAFLET
PRODUCED SEPTEMBER 2004
UPDATED MAY 2011