Hidradenitis Suppurativa / Acne Inversa
Hidradenitis suppurativa (HS), also called acne inversa, is a chronic, persistent and relapsing inflammatory disease of the pilosebaceous unit. It is marked by painful inflamed nodules, abscesses under the skin, chronically draining tunnels and disfiguring fibrotic scars. It mainly affects skin that is rich in apocrine sweat glands and subject to constant friction.
HS was once mistaken for an infection or a simple sweat gland disorder, but we now know its core mechanism is immune dysregulation combined with blockage of the hair follicle opening:
- Hyperkeratosis and follicular occlusion: keratinocytes at the follicle opening overgrow and stick together abnormally, plugging the outlet of the pilosebaceous unit.
- Follicle rupture and an inflammatory surge: trapped sebum and dead cells stretch the follicle until it bursts. Its contents spill into the dermis and trigger the innate immune system, which releases powerful inflammatory cytokines such as TNF-α, IL-1β, IL-17 and IL-23.
- Tunnel formation and fibrosis: long-standing inflammation destroys the surrounding tissue, forming deep abscesses under the skin that connect through a network of sinus tracts (tunnels), leading to contracting fibrotic scars and severe damage to the skin's structure.
- Risk factors and associations: HS is closely linked to genetics (gamma-secretase gene mutations), smoking, obesity, metabolic disorders and fluctuations in androgen hormones.
At Haute-Derma, our care for patients with hidradenitis suppurativa starts with accurate diagnosis and staging, then combines control of systemic inflammation, simple and effective care of draining wounds, and long-term support for tissue recovery.
Clinical Features and Hurley Staging
HS is assessed clinically by the type of lesions, where they occur and the standardized Hurley staging system:
- Typical locations: lesions appear symmetrically in high-friction skin folds such as the armpits, groin, perianal and perineal area, under the breasts, abdominal folds and the cleft between the buttocks.
- A range of lesion types:
- Deep, red, firm painful nodules.
- Abscesses under the skin that tend to rupture and keep draining foul-smelling pus.
- Double-headed comedones or blackheads in skin folds, a very characteristic clinical sign of HS.
- Winding tunnels linking abscesses under the skin, and thick, rope-like hypertrophic scar bands.
- Hurley Staging System:
- Hurley stage I: one or more single or scattered nodules or abscesses; no tunnels and no scarring yet.
- Hurley stage II: recurrent abscesses; scattered tunnels have formed and scarring has begun, but lesions are still separated from one another.
- Hurley stage III: widespread disease; an interconnected network of tunnels links abscesses and fibrotic scar bands across an entire anatomical area.
The Haute-Derma Approach to Diagnosis and Treatment
- Thorough medical diagnosis and accurate staging: The doctor examines the skin, identifies the characteristic lesions (painful nodules, abscesses, double-headed comedones) in the skin folds and determines the Hurley stage. We also take a detailed history of family background, lifestyle and associated conditions (diabetes, metabolic syndrome, inflammatory bowel disease).
- Medical treatment to control inflammation: an individualized plan based on disease stage:
- Mild disease: a topical antibiotic (clindamycin) together with a soap-free antibacterial wash.
- Moderate to severe disease: long-term oral antibiotics (clindamycin plus rifampicin, or doxycycline) for their anti-inflammatory and immunomodulating effects. For treatment-resistant cases, we work with specialist colleagues to start biologics targeting TNF-α (such as adalimumab) or IL-17 to shut down systemic inflammation.
- Targeted procedures and surgery: these include draining abscesses when needed, injecting corticosteroid into acutely inflamed nodules, deroofing of tunnels, and wide surgical excision of affected tissue in stage III disease to prevent recurrence.
- Skin care, lifestyle management and emotional support: We show patients how to change dressings gently using non-adherent gauze and how to soothe affected skin. We also advise on weight loss, help with quitting smoking and recommend an anti-inflammatory diet to improve symptoms over the long term.
Clinical Forms and Factors Associated With Hidradenitis Suppurativa
| Factor / Presentation | Mechanism and Clinical Features |
|---|---|
| Classic axillary and inguinal form | The most common form. Deep, painful nodules rupture, drain pus and form tunnels in both armpits, the groin and the genital folds. |
| Follicular occlusion triad / tetrad | HS belongs to a group of follicular keratinization disorders and can occur together with acne conglobata, dissecting cellulitis of the scalp and pilonidal sinus. |
| Fibrosis and reduced mobility | Long-standing inflammation creates hard, contracting scar bands in the armpits or groin that can severely limit arm and leg movement. |
