Hidradenitis suppurativa
Hidradenitis suppurativa is a long-term skin condition in which painful lumps keep appearing in the armpits, the groin, under the breasts and between the…
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Medicines commonly prescribed for Hidradenitis suppurativa
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: CREAM, 1 mg/gActive substance: mometasoneManufacturer: Glenmark Arzneimittel GmbhPrescription requiredDosage form: INJECTABLE, 40 mgActive substance: adalimumabManufacturer: Samsung Bioepis Nl B.V.Prescription requiredDosage form: INJECTABLE, 40 mgActive substance: adalimumabManufacturer: Samsung Bioepis Nl B.V.Prescription required
Hidradenitis suppurativa is a long-term skin condition in which painful lumps keep appearing in the armpits, the groin, under the breasts and between the buttocks. Some settle on their own, others burst and discharge pus, and where they have healed the skin is left with drawn-in scars and tunnels running beneath it. It affects roughly one person in a hundred, women more often than men, and it usually begins after puberty. Medical letters give it several names — acne inversa, Verneuil's disease — but they all mean the same thing.
First the thing that weighs most heavily on people who have it: this condition has nothing to do with poor hygiene, it is not catching, and it is not sexually transmitted. Washing more than usual achieves nothing, and scrubbing the affected areas does harm.
What is actually happening in the skin
The old name left behind the notion that sweat glands are to blame. They are not. Everything starts at a hair follicle: its opening becomes blocked, contents build up, the wall gives way and ruptures inwards into the surrounding tissue. The immune system reacts to that spilled material with fierce inflammation, and out of it come the lump, the pain and the pus. Such lumps arise where skin rubs on skin and where the larger glands are plentiful, which is why the condition is tied to armpits and groin; but the glands are the neighbours, not the cause.
The inflammation then travels deeper and sideways. Neighbouring follicles are drawn in, tunnels open between the affected spots — narrow tracts under the skin that seep fluid — and where inflammation has burnt out a hard scar remains, pulling the skin tight. It is the scars and tracts that make advanced disease so hard to deal with, which is exactly why it is worth catching early.
What it looks like and where it turns up
The start usually goes unremarked: one or two painful pea-sized lumps taken for a boil or an infected ingrowing hair. Within days the lump either settles or bursts. Then the whole thing repeats — and it is that repetition in the same place which sets hidradenitis apart from a chance abscess.
The usual sites:
- the armpits;
- the groin and the external genitals;
- the buttocks and the skin around the back passage;
- under the breasts and in the fold beneath them;
- the inner thighs, the waistband area and the back of the neck.
Nearby there are often double and triple blackheads sitting as though on a shared base — a sign that tells a doctor a great deal. Some people also turn out to have acne, excess hair growth and a pilonidal sinus, the small tract in the skin above the tailbone.
Severity varies enormously: for some it stays at a few lumps a year, for others a whole area is covered in scarring and discharges constantly. The grade is what decides the treatment.
What feeds the fire
The precise cause is unknown, but what makes it worse and what travels alongside it are well established.
- Smoking. The strongest link of all. In smokers the course is more severe, flares are more frequent and surgical results are worse.
- Excess weight. More folds, more friction, more sweat — and fatty tissue keeps the inflammation going in its own right. Losing weight noticeably eases the course.
- Friction and pressure. Tight clothing, harsh seams, a rucksack, a belt, long hours sitting.
- Hormones. The condition starts after puberty, in many women it flares before a period, and in pregnancy it may either quieten down or worsen.
- Family history. About a third of those affected have relatives with the same thing.
- Conditions that keep it company. Crohn's disease, polycystic ovary syndrome, metabolic disorders and inflammatory arthritis all turn up more often than expected. If the disease sits around the back passage, it is worth asking about the bowel: Crohn's disease can look very similar and needs entirely different treatment.
Shaving and deodorants do not cause the condition, but they irritate skin that is already inflamed, so it is better to keep the razor away from affected areas.
Why the diagnosis so often arrives late
Years frequently pass between the first lumps and the right diagnosis. Someone carries on with what everyone calls boils, the abscess is drained again and again, another short course of antibiotic is handed over, and meanwhile the disease moves on.
There is no specific test for hidradenitis: the diagnosis rests on three things together — characteristic lesions, characteristic sites, and recurrence. A swab is not taken to confirm anything but to see whether an ordinary bacterial infection has joined in; frequently nothing grows at all, which is what one would expect, because the disease is inflammatory by nature rather than infectious.
Hence a practical conclusion: if a painful lump comes up in the armpit or groin for the second or third time in six months, do not wait for the next drainage — ask to be referred to a dermatologist.
What it is treated with
There is no remedy that cures it outright, but the course can be managed, and starting early can head off the scarring altogether. Treatment climbs in steps, from things applied to the skin to things taken by mouth or injection.
- Topical treatment. Antiseptic solutions and washes for the affected areas, a topical antibiotic from the lincosamide group, benzoyl peroxide preparations.
- Antibiotics by mouth. In milder disease, a long course from the tetracycline group taken for several months, prescribed not because bacteria have been found but for its anti-inflammatory effect. In more severe disease a combination of two drugs is used.
- Hormonal treatment for women. Combined contraceptives and drugs with anti-androgen action help when flares track the menstrual cycle.
- Retinoids, derivatives of vitamin A, prescribed by a dermatologist only. They are incompatible with pregnancy, and after finishing acitretin pregnancy must be avoided for a further three years, so women planning a family are generally not given them.
- Biologic drugs. In severe and stubborn disease, medicines that block specific links in the inflammatory chain are used: tumour necrosis factor inhibitors and drugs directed against interleukin-17. They are given by injection under the skin, a dermatologist prescribes them, and hidden infections are ruled out before starting.
- Steroid injected into the lesion. A corticosteroid put straight into a fresh painful lump settles the inflammation quickly and often saves it from having to be opened.
- Pain relief. The pain here can be severe and there is no merit in enduring it. The doctor works out the regimen, and for persistent pain drugs acting on nerve pain are added.
An important point about lancing. An incision takes the pain away for a few days but removes neither the tract nor the scar, and the lump returns to the same spot. As a one-off measure for a tense, painful lesion it is justified; as a treatment plan it is not.
When a surgeon is needed
Surgery comes up when lesions keep recurring in one place or when an area has already been remade out of scars and tracts.
Smaller procedures take the roof off a tract and leave the base to heal open — that clears one stubborn lesion while sparing the surrounding skin. In extensive disease the whole affected area is cut out, sometimes with reconstruction afterwards; that is the most durable answer for a given area, but healing takes a long time. Laser hair removal helps a proportion of people, since it removes the follicles themselves. Surgery does not replace medication: without it the disease simply starts up in the area next door.
Daily care, pain and mood
- loose clothing in soft fabrics, with no harsh seams at the armpits or groin;
- gentle washing without rubbing, with an antiseptic wash if the doctor advises one;
- a warm damp compress on a painful lump, which eases it and helps it drain;
- absorbent dressings over discharging areas so clothes do not stick;
- where possible, losing weight and stopping smoking: these are the only two measures that alter the course of the disease and not merely how you feel;
- not squeezing the lumps, since the contents travel inwards rather than out;
- not shaving the affected areas.
And separately the psychological side, which usually goes unmentioned. Constant pain, odour, the business of changing dressings and the intimate siting of the lesions all take their toll on self-esteem and on relationships. Depression is considerably more common in people with this condition than in the population at large, and it is not a weakness of character but the predictable consequence of chronic pain and isolation. If you have caught yourself thinking that living like this is not worth it, say so to your doctor — that is as much a part of treatment as any cream.
When not to put off an appointment
See a doctor without delay if:
- a temperature and shivering appear and redness is spreading rapidly beyond the lump — signs that an infection has joined in;
- the pain has become unbearable, or a lesion has suddenly enlarged;
- a tract has formed that leaks fluid continuously;
- moving an arm or a leg has become difficult because scarring is pulling the skin tight;
- marked fatigue sets in: prolonged inflammation drains the body and leads to anaemia;
- the external genitals become swollen.
One separate and uncommon danger is worth knowing about. In lesions that have been present for a great many years, particularly on the buttocks and around the back passage, a squamous cell skin cancer occasionally develops. Warning signs are an ulcer that will not close, tissue growing outwards, pain that has changed in character, or bleeding at an old site. It happens rarely, and that is precisely why long-standing lesions need medical oversight: any change in an old lesion is a reason to be seen rather than to wait.
Online consultation
In an online consultation the doctor will go through how long the lumps have been coming and how often, exactly where, whether flares follow the cycle, what you have already taken and what helped. From the description and a few photographs the severity can be graded, and you will be told what can be started at once, which tests are needed, and whether the next step is a dermatologist or a surgeon. The neighbouring questions are well suited to an online appointment too — contraception, weight, bowel or joint symptoms, pain control — as is agreeing in advance what to do at the next flare.
This material is for information only and does not replace medical advice.
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