What is hidradenitis suppurativa (HS)?
HS is a long-term (chronic), recurrent skin disease that presents as painful bumps and boil-like lesions in the folds of the skin. It mainly affects underarms, the area under the breasts, and the groin and buttock area. HS is not an infection, is not contagious and is not caused by poor hygiene.
What does HS look like?
There are a variety of skin changes seen in HS. These can include multiple blackheads (open comedones), recurrent painful bumps, abscesses and tunnels under the skin (sinus tracts). These lesions can leak pus or blood. They can also be very painful or uncomfortable. With time, repeated and long-term inflammation can lead to scarring.
What causes HS?
The exact cause of HS is still unclear. There seem to be several factors that can contribute to developing HS. There might be some genetic predisposition. There might also be environmental factors that contribute, such as friction or rubbing. Hormones might also play a role. Ultimately, boils develop when there is blockage of the hair follicles, followed by rupture (bursting) and inflammation under the skin.
Who gets HS?
HS is more common in females and in the Black population. It is also more common after puberty.
HS can sometimes run in families
HS is more common in individuals who smoke, as well as in individuals who are overweight. However, not everyone with HS has these characteristics.
What conditions are associated with HS?
There are a variety of conditions that are seen more commonly in people with HS. People with HS are considered to be at higher risk of the following:
- Metabolic syndrome (including high blood pressure, high cholesterol, type 2 diabetes, and obesity)
- Heart attacks and strokes
- Inflammatory bowel disease, especially Crohn’s disease
- Acne
- Other inflammatory or specific genetic syndromes
Some patients can have associated acne or pilonidal sinus (a chronic abscess at the base of the spine).
Is there a cure for HS?
HS is typically a chronic, recurrent disease, meaning that it keeps coming back. Individual bumps may last for weeks or months. Unfortunately, there is no cure; however, there are treatments that can help keep HS under control.
How is HS diagnosed?
Diagnosis is made by your child’s doctor, based on history, symptoms and examining your child’s skin. There is no specific test to diagnose HS. Sometimes, there is a delay in diagnosing HS as it can be initially diagnosed as infection or folliculitis.
What are the treatment options for HS?
Treatment for HS should be individualized to each patient. While there are best-practice guidelines for treating HS in adults, these do not yet exist for children and adolescents with HS. Treatments for HS can take weeks to months to work and must be continued long term in most cases. It is important for your child to continue on their long-term treatments and to follow their doctor’s recommendations.
Topical treatments
Milder forms of HS can be managed with topical medications applied directly to the skin. Some of these medications are the same ones used to treat acne. Common topical treatments used include antibiotics (such as clindamycin), benzoyl peroxide and vitamin A derivatives (also called retinoids). These are often used together. Diluted bleach baths may also be helpful.
Local injections
For a painful boil, your child’s doctor may offer a steroid injection into the boil.
Oral antibiotics
When HS affects more of the body, oral antibiotics may be prescribed for a prolonged period of time (months) to control inflammation. These antibiotics are used primarily for their anti-inflammatory action, and not because there is an active infection. Commonly used antibiotics for HS include doxycycline, macrolides, clindamycin and rifampicin. Some antibiotics may be combined (e.g., clindamycin and rifampicin are often used together). Your child’s doctor will discuss possible side effects with you.
Hormonal therapy
As hormones play a role in HS, some people who menstruate can notice that their HS flares with their menstrual cycle. In these cases, oral contraceptive pills or spironolactone can be helpful.
Metformin could be an option in patients with insulin resistance.
Oral retinoids
Isotretinoin (Accutane) and acitretin are sometimes helpful, especially if there is associated acne.
Biologic therapy
For more severe HS, biologic medications can be considered. These treatments are designed to target specific parts of the inflammatory pathway in the body. They are mostly given by injection. One biologic used frequently in HS is adalimumab, but sometimes other biologic medications may also be tried.
Surgery
Surgery may be needed for areas that are repeatedly impacted by HS, particularly when they do not respond to medications.
Behavioural strategies
Certain strategies can help HS, especially when used together with the medicines prescribed by your child’s doctor. When boils are painful and inflamed, warm compresses can help encourage draining, which can provide some relief. Pain medicines can be used to help manage pain caused by the skin lesions. Maintaining a healthy weight and not smoking can help to make HS less severe.
There is no way to prevent your child from getting HS. However, there are many strategies for people who have HS to help keep the HS under control. These include:
- Maintaining a healthy weight
- Wearing loose-fitting clothing to prevent friction in skin folds
- For individuals who smoke, quitting has been shown to make their HS less severe
- Taking a bath or shower every day, making sure to gently wash areas affected by HS. Scrubbing too hard can make affected areas more tender.
HS can lead to a number of complications and changes in the skin. These can include:
- Pain
- Draining pus or blood
- Scars
- Pigment changes
- Secondary infection
The changes in the skin can also lead to a significant impact on quality of life. Some people experience shame or humiliation because of the appearance or the associated odour. Pain can limit the ability to do certain activities. Some people can develop depression or anxiety related to their skin condition.
HS can be challenging to manage. For some people, having to deal with painful, draining and/or foul-smelling lesions can lead to anxiety, depression and isolation. Talking to someone about coping with this chronic disease may help. Your child’s doctor can help connect you with a counselor and support groups.