INTRODUCTION
Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease that predominantly affects young adult females in the second and third decades of life.1 Clinically, HS is characterized by painful dermal abscesses, subcutaneous inflammatory nodules, draining sinuses, and hypertrophic scars involving the axillae, anogenital region, breast, areola, and periumbilical region.2 HS can be associated with malodorous discharge and significant disfigurement, which may have a large impact on the patients’ quality of life.3
The pathogenesis of HS is not fully elucidated; however, lesion formation is believed to be centered around follicular occlusion within apocrine glands resulting in debris accumulation, leading to cyst formation. Eventually, the hair follicle will rupture, followed by a local immune response resulting in substantial inflammation.4 In advanced cases, the sinuses in HS can dissect into fascia and muscle, forming tracts.2 Genetic factors, immune dysregulation, hormonal imbalance, and lifestyle influence also play a role in the development of HS.5 Common associated comorbidities include obesity; as well as HTN, metabolic syndrome, depression, diabetes mellitus, Crohn’s disease, and cardiovascular disease. Additionally, there is a strong association between smoking and HS.1
Historically, HS has been treated by a number of different specialties including surgeons, emergency physicians, infectious disease specialists, general practitioners, and dermatologists. The lack of cohesive care has led to variations in the approach to the signs and symptoms of HS, as well as disease management. This fragmentation in care may lead to a delay in diagnosis of HS, reported to range from 5-14 years.6 Early lesions of HS mimic other skin conditions and are often misdiagnosed as recurrent furunculosis, or folliculitis.7,8 Rapid recognition and initiation of treatment can reduce the risk of HS progression to debilitating end-stage disease, which involves the diffuse development of sinus tracts and abscesses across an entire body surface.7,9 It is imperative that HS be promptly diagnosed and managed to avoid long-term consequences such as depression, anxiety, and scarring which can be associated with mismanaged HS.10
Practical Interventions
HS is a complex disease that requires a patient-centered approach, including management of the disease, its comorbidities, and flare prevention.5 While there is not a cure for HS, symptoms can be managed and recurrence can be reduced following various lifestyle changes.11 Common goals of management include prevention of disease progression, reducing the frequency of recurrence, and treating existing lesions to minimize pain and drainage.12
Weight Loss
The link between HS and obesity is rooted in obesity’s inflammatory nature, which creates a milieu of pro-inflammatory cytokines including interleukin (IL)-1, IL-6, and tumor necrosis factor (TNF)-alpha – all of which mediate inflammation seen in HS. Furthermore, having increased inverse skin areas in the axilla and inguinal folds poses opportunity for localized friction leading to follicular hyperkeratinization and occlusion.13
The pathogenesis of HS is not fully elucidated; however, lesion formation is believed to be centered around follicular occlusion within apocrine glands resulting in debris accumulation, leading to cyst formation. Eventually, the hair follicle will rupture, followed by a local immune response resulting in substantial inflammation.4 In advanced cases, the sinuses in HS can dissect into fascia and muscle, forming tracts.2 Genetic factors, immune dysregulation, hormonal imbalance, and lifestyle influence also play a role in the development of HS.5 Common associated comorbidities include obesity; as well as HTN, metabolic syndrome, depression, diabetes mellitus, Crohn’s disease, and cardiovascular disease. Additionally, there is a strong association between smoking and HS.1
Historically, HS has been treated by a number of different specialties including surgeons, emergency physicians, infectious disease specialists, general practitioners, and dermatologists. The lack of cohesive care has led to variations in the approach to the signs and symptoms of HS, as well as disease management. This fragmentation in care may lead to a delay in diagnosis of HS, reported to range from 5-14 years.6 Early lesions of HS mimic other skin conditions and are often misdiagnosed as recurrent furunculosis, or folliculitis.7,8 Rapid recognition and initiation of treatment can reduce the risk of HS progression to debilitating end-stage disease, which involves the diffuse development of sinus tracts and abscesses across an entire body surface.7,9 It is imperative that HS be promptly diagnosed and managed to avoid long-term consequences such as depression, anxiety, and scarring which can be associated with mismanaged HS.10
Practical Interventions
HS is a complex disease that requires a patient-centered approach, including management of the disease, its comorbidities, and flare prevention.5 While there is not a cure for HS, symptoms can be managed and recurrence can be reduced following various lifestyle changes.11 Common goals of management include prevention of disease progression, reducing the frequency of recurrence, and treating existing lesions to minimize pain and drainage.12
Weight Loss
The link between HS and obesity is rooted in obesity’s inflammatory nature, which creates a milieu of pro-inflammatory cytokines including interleukin (IL)-1, IL-6, and tumor necrosis factor (TNF)-alpha – all of which mediate inflammation seen in HS. Furthermore, having increased inverse skin areas in the axilla and inguinal folds poses opportunity for localized friction leading to follicular hyperkeratinization and occlusion.13
