An Overview of Hidradenitis Suppurativa

This painful skin condition is often misdiagnosed

In This Article

Hidradenitis suppurativa is a chronic, scarring skin disease that affects the apocrine, or sweat glands. It causes painful lumps and boils on the skin, especially in the armpit, groin, breast, and anal area. It is a common condition but is frequently misdiagnosed and can be disabling and distressing for the person who is affected. Hidradenitis suppurativa does not occur before puberty. Rather, most people are between 20 and 40 years old when they develop it. Also, women are three times more likely than men to develop it.

Hidradenitis suppurativa is also called acne inversa.

Symptoms

Hidradenitis suppurativa occurs in areas of the body that contain sweat glands including the armpits, groin, upper thighs, buttocks, scalp, and under the female breasts.

Early symptoms include:

  • Pimple-like bumps (but they occur in areas you typically do not find acne, like under the armpits and in the groin area)
  • Blackheads, which tend to develop in pairs (again, appearing in areas where you wouldn't typically find acne)
  • Painful lumps under the skin, which may be up to marble-sized
  • Boils

Symptoms may come and go. When the condition is mild, it may present only as a cluster of two or three blackheads that communicate under the skin.

Once the disease begins, it gets progressively worse. The boils can be very painful and restrict the movement of the affected area. They may also rupture and leak fluid, which often has a foul odor.

The extensive, deep inflammation leads to painful abscesses. These abscesses heal incompletely and cause cord-like scars on the skin. In addition, the infection can progress under the skin in tracts linking the abscesses. The tunnels can cause deep scarring under the skin.

Causes and Risk Factors

The exact cause of hidradenitis suppurativa is disputed. Since it looks similar to acne, some scientists believe that it is caused by the formation of keratin plugs in follicles. That being said, because hidradenitis suppurativa occurs in areas that contain apocrine, or sweat, glands, other scientists believe that it is caused by a blockage of the apocrine gland.

In either case, the plugged gland or follicle becomes larger, ruptures, and becomes infected. The condition most often develops in areas that have many sweat glands (armpits, groin, etc.) and where the skin rubs together.

Hidradenitis suppurativa is more common in women than in men. It is also more common in those who have acne, and those with a family history of the condition.

Obesity and cigarette smoking may be triggering factors.

Hidradenitis suppurativa is not contagious, so it cannot be spread to others. It is also not a result of poor hygiene.

Diagnosis

Hidradenitis suppurativa is diagnosed by a doctor based on its appearance. There are no lab tests or biopsies that establish the diagnosis.

In the early stages, hidradenitis suppurativa resembles isolated boils, or infected hair follicles. Symptoms often come and go.

Hidradenitis suppurativa is likely to be misdiagnosed, especially in the early stages. Many people have this condition for a long while, sometimes years, before getting an accurate diagnosis.

Repeated breakouts are one clue that something beyond just a simple boil or inflamed hair follicle is happening. As breakouts continuously appear and heal, they often form scar tissue, often creating bands of scarring that can restrict the movement of the limb over time. This is another giveaway that the condition is hidradenitis suppurativa.

Many people are embarrassed by the multiple infections, thinking that they have ingrown hairs in sensitive areas, as well as by the smell that leaks out of the breakouts. Due to this embarrassment, they do not go to the health care provider until the boils have become numerous or intolerable.

If you have hidradenitis suppurativa, it's important to know that this skin condition is not your fault. Your doctor has "seen it all," so to speak, and will not be shocked about the condition of your skin. Remember, your doctor wants to help you.

Treatment

Treating hidradenitis suppurativa can be difficult. It is best treated in the early stages before extensive scarring develops. However, it must be diagnosed correctly.

Antibiotics

Oral antibiotics (those taken by mouth) may help suppress the inflammation, especially in mild cases, but they do not cure the disease. The same antibiotics that are used for acne are used for hidradenitis suppurativa, only in higher doses. These antibiotics include erythromycin, tetracycline, minocycline, and doxycycline.

Topical antibiotics (those applied to the skin) can also be used in cases of mild hidradenitits suppurativa.

Biologics

Humira (adalimumab) was approved by the U.S. Food and Drug Administration (FDA) in 2015 for people ages 12 and older who have moderate to severe hidradenitis suppurativa. It is a biologic agent that helps reduce inflammation.

In clinical trials, Humira also improved nodules and abscesses that come with this condition.

Hormone Therapy

Some women see much improvement when treated with hormone therapy, namely oral contraceptives, finasteride, or spironolactone. This is especially true for women who get flareups right before their menstrual cycle. It's believed that these treatments balance hormones that may contribute to inflammation.

Isotretinoin (Accutane)

Isotretinoin may be helpful in mild cases, but the response is unpredictable. Sometimes isotretinoin is used to reduce the size of the affected areas prior to surgery.

Isotretinoin does have significant side effects and must not be used by pregnant women.

Steroid Injection

Injecting a steroid into an inflamed lesion is sometimes helpful. The injection helps reduce inflammation and may be used if an area is especially painful. Steroid injections are normally combined with other treatments and are not used as the sole treatment for hidradenitis suppurativa.

Surgery

In moderate-to-severe cases of hidradenitis suppurativa that aren't improving with other treatments, surgery is the most definitive option. That being said, removal of only the immediately affected area leads to recurrence of the disease.

Instead, the treatment of choice is called wide local excision. In this procedure, the affected area and the surrounding normal tissue are surgically excised. The excision is not stitched back together but left open to heal from the inside out. Skin grafts may be placed in the excised area to speed healing.

Coping

Hidradenitis suppurativa can be a debilitating condition because it can be so painful. Pain can make it difficult to move around, especially if the breakouts occur in the groin or buttocks area.

Studies have shown that people with hidradenitis suppurativa have higher rates of depression compared to people with other skin diseases, and quality of life is on par with those who have serious health conditions such as cardiovascular disease and cancer.

In addition to the odor, many people also feel embarrassed about discharge leaking onto clothes. This can cause people to isolate themselves, leading to anxiety and depression.

If you have this condition, it's important to seek out support, whether it be from friends and family or from support groups, locally or online.

Let your doctor know exactly how this condition is impacting your life. If you're in pain, if you're having continued breakouts, or if you're feeling depressed, your treatment is not working as effectively as it could. Your doctor can work with you to help you find relief.

A Word From Verywell

If you suspect that you or a loved one has hidradenitis suppurativa or another painful skin condition (like frequent boils or acne-like cysts), please see a dermatologist for a proper diagnosis. Early diagnosis of hidradenitis suppurative is essential in preventing it from getting worse. 

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Article Sources

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial policy to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Lee EY, Alhusayen R, Lansang P, Shear N, Yeung J. What is hidradenitis suppurativa? Can Fam Physician. 2017 Feb;63(2):114-120.

  2. Dufour DN, Emtestam L, Jemec GB. Hidradenitis suppurativa: a common and burdensome, yet under-recognised, inflammatory skin disease. Postgraduate Medical Journal. 2014;90:216-221. doi:10.1136/postgradmedj-2013-131994

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