Understanding Hidradenitis Suppurativa: Causes & Treatments

Hidradenitis suppurativa (HS) is a progressive skin condition affecting the hair follicles in certain areas on the body resulting in abscesses, fistulas and scarring. It can be centered around the pubic hair, armpits, and other areas that rub together frequently, like under breasts, and areas that contain apocrine sweat glands (the human milk line). The follicle becomes blocked, ruptures, and spreads debris into nearby tissue.

The lesions can create tunnels under the skin (sinuses), connecting each other. The condition was previously thought to originate in the apocrine sweat glands, however now it is understood that the condition stems from inflamed hair follicles.

Possible causes of hidradenitis suppurativa

HS is caused by ongoing inflammation in the hair follicles common in young women. It is unknown why this condition manifests in some people, but it is known to run in families (hereditary) and is more prevalent in overweight people. It is also worse in smokers, who may find quitting smoking spontaneously cures their HS. It could be caused by an immune response to bacteria living on the skin in these areas.

HS is influenced by hormones, so any hormonal abnormalities can make this condition worse, but researchers are not sure why. Women find their fertile and menstruating years the most frustrating, since hormones are the most active during this time.

Symptoms often get worse immediately before periods, and improve with pregnancy. Androgens have been blamed, however that doesn’t always stack up, since androgens are high at puberty, but this condition doesn’t usually appear until later on. Women with HS don’t have higher-than-usual androgens, and most hormone profiles show normal levels.

Mechanical stress is also a factor – long, bumpy car rides, shaving, running, and so on. The immune system may play a greater role than previously thought, and HS has been linked with Crohn’s disease (in one study, 17 per cent of those with Crohn’s had HS), since they share a lot of characteristics and risk factors.

Symptoms of hidradenitis suppurativa

Symptoms can get very distressing and even disabling, or in fact be quite minor. Distress is very common – this is is a very disturbing condition, and you would be right to be upset.

Painful lumps
Abscesses
Large blackheads
On the vulva, affects skin under pubic hair, outer labia, groin, area around the anus and at times, the buttocks
A variety can result in small lumps on the inner surface of the inner labia

How do I know if I hidradenitis suppurativa?

The way this condition is diagnosed is by a series of questions by your doctor. Diagnosis can be hard to make due to the generic sort of nature of the lumps over time – they are similar to several other conditions, including acne. They consist of lumps, usually in the armpit or groin (along the milk line – see diagram).

Questions you may be asked:

Do you have painful or tender red papules (like pimples) smaller than 1cm in diameter?
Do you have painful or tender nodules (growths under the skin) bigger than 1cm in diameter?
Do you have a painful or tender abscess, with inflamed papules or nodules with discharge coming from them?
Is there a rope-like elevation of the skin or other ridges in the skin?
Double-headed blackheads? (double-ended comedones)

A diagnosis is made of hidradenitis suppurativa if you have:

One or more primary lesions at the armpit or groin, and a history of three or more discharging, painful lumps (not specified) in the key zones since age 10; or
Inactive disease with a past history of five or more discharging or painful lumps (unspecified) in key sites since age 10, without current primary lesions.

Tests for hidradenitis suppurativa may include:

A full blood count
Urinalysis
Iron levels
Bacterial sample of exudate
Tests for checking inflammation levels in the body
Ultrasound of area

Classifications of hidradenitis suppurativa

Hurley stage I – usually prescribed antibiotics and corticosteroid injections, with flare-ups treated with oral corticosteroids. Zinc or antiandrogen therapy (in infertile women) may be offered.
Hurley stage II – same as stage I, but may be accompanied by long-term immunosuppressive therapy or surgical therapies.
Hurley stage III – after all else has failed or the condition is advanced, wide excision (removal of a large area of skin) might be the only solution.

Treatment of hidradenitis suppurativa

HS is not an infection, so antibiotics work in other ways, primarily to reduce inflammation, and are often prescribed for this reason (despite the damage done by long-term use of antibiotics, which is not ideal, and another option should be investigated prior to antibiotics). Abscesses can be lanced, or the lumps cut out, but the lumps usually return even after surgery.

HS is not something to be ‘cured’, but just managed. It’s like having a tendency to asthma or eczema – that tendency doesn’t go away, but with medication, self-care techniques and avoidance of triggers, generally most sufferers can keep it under control or it may even spontaneously disappear.

HS is a very challenging condition to treat, and needs your full attention, so if you are overweight or smoke, this needs to change. There are a handful of treatments available, none of them great or that effective. Your case will be managed using your particular circumstances and symptoms.

It’s important to maintain good hygiene and basic levels of care while you investigate other treatments. That means avoiding anything that will aggravate inflammation (perfumes, irritants, soaps, etc.), wear loose-fitting clothes, use laser hair removal (don’t shave or wax), and where necessary, apply warm compresses to help drain abscesses. Talk to your doctor about your options, but also get the views of an experienced natural therapist (naturopath or herbalist) – this is precisely the type of condition that often responds very well to herbs, changes in diet and lifestyle, and a few choice tips for living.

Medical treatments for hidradenitis suppurativa

Long-term antibiotics: A common treatment is a long-term oral tetracycline antibiotic (minomycin or doxycycline). Keep in mind HS is not an infection, but inflammation, and tetracyclines are known to have an effect on inflammation. If you are taking antibiotics for any length of time (in particular long-term), you must help preserve your good bacteria by taking a good-quality probiotic and eating lots of fermented foods.
Repeated lancing, incision and drainage: this is draining the abscesses of pus and debris, to reduce local inflammation and discomfort. This is only a short-term solution, however, and it usually needs to be repeated.
Corticosteroids (injected into lesions): flare-ups can be injected with steroids, which will get the inflammation down and help prevent scarring and damage, though this is not always sustainable, depending on the extend of the condition.
Clindamycin cream: this is an antibacterial cream.
Oral contraceptive pill (OCP): the pill can help reduce androgen levels, thereby exerting an effect on symptoms.
Antiandrogen medication: like the pill, reducing androgens may help the condition, though this is usually only recommended to infertile women (past menopause).
Laser hair removal: modest improvements found in some people.

Naturopathic ideas for treating hidradenitis suppurativa

It seems clear that the inflammatory process is hard at work in HS, so doing everything possible to interrupt the inflammatory process will help to interrupt HS, even if we can’t figure out what the cause is.

While this is by no means a comprehensive treatment plan (you need to see a real-life practitioner for that, and you should), it will get you started and headed in the right direction. Nothing offered here will hurt you. To be clear, the cause of HS is not inflammation; we do not yet know the cause, but managing inflammation will help to calm your symptoms.

Diet and inflammation in hidradenitis suppurativa

There is a lot of information available online about inflammation and diet. Find a site that appeals to you, check the credentials of the site authors (very important! everyone and their dog seems to have an opinion about this topic) and start at once on an anti-inflammatory regime. This is for life, so take it slow, and get it right.

Get recipe books, learn how to cook, and embark on your anti-inflammatory journey. It can be hard at first (pizza is delicious), but this skin condition will be harder, and unlike your skin condition, after a while, you will start to enjoy the diet, you will start to feel better, and as time goes by, your skin condition should start to improve. At worst, you feel better; at best, it sorts your skin out.

This means erring towards a pesco-vegan diet, and sticking to whole, real food, lightly cooked, at all times. It also means, at least for a while, ditching soda, fried foods, smoking, drinking (except red wine of course!), recreational drugs, dairy, red meat, and crappy fats (margarine and co). You may want to ease off bread and other wheat products, and eat more brown rice.

The diet really needs to be pretty strict at first, for three months until you can see if it is making improvements to your body. Keep a diary.

This is no mean feat – changing your diet can be traumatising for most of us, who are used to sugary, fatty, salty foods that are often very poor quality, and very, very inflammatory. Anything burnt, browned, fried, heated to high temperatures, cheesy, bready and meaty is going to trigger off your little inflammatory molecules, so they must go if you want to temper inflammation.

How inflammation works

Everything you put in your mouth either releases inflammatory molecules into the blood, that then inflame particular tissues, or, it sends out little anti-inflammatory molecules that reverse that impact, which is why fish oil is good.

It floods your system with anti-inflammatory molecules in much higher doses than you would normally be able to produce just from food alone. You want to reverse the impact of inflammation and damp down the inflammatory response that the HS has caused (or been caused by).

Supplements to consider

At least 500mg EPA per day in high-quality fish oil (this may be 4 or more capsules – check the label for specific amounts, choose good fish oil)
4,000IU vitamin D, unless you live in a very sunny place and get sun every day without sunscreen (take these with fatty food like avocado or nuts, as it digests better)
At least 2 litres of water (can be heavily diluted juices, water, herbal tea, juicy fruits)

Seeing an alternative medicine practitioner for hidradenitis suppurativa

See an holistic nutritionist, herbalist or naturopath for help with your diet and supplements/herbs that will directly impact skin and immune functioning.

Additionally, see if they can observe any hormonal imbalance signs and symptoms in you. These types of conditions are really where natural medicine has an opportunity to shine, since there aren’t really any sure-fire cures or even very good treatments available.

Make sure the person you see is qualified and experienced, and you like and trust them with your health. Call ahead and ask to speak to them if you want to – you can!

References

Nazary, M., et al., Pathogenesis and pharmacotherapy of Hidradenitis suppurativa, Eur. J. Pharmacol. (2011), doi:10.1016/j.ejphar.2011.08.047 [Research Gate – PDF]
Thomas R, Barnhill D, Bibro M, Hoskins W. Hidradenitis suppurativa: a case presentation and review of the literature. Obstet Gynecol. 1985 Oct. 66(4):592-5. [Medline].
Short KA, Kalu G, Mortimer PS, Higgins EM. Vulval squamous cell carcinoma arising in chronic hidradenitis suppurativa. Clin Exp Dermatol. 2005 Sep. 30(5):481-3. [Medline].