hid. suppurativa

22 Jul

Hidradenitis supperativa is a long term, inflammatory condition that affects the hair follicle. This creates abscesses (large lumps with pus), scarring and pain. It is usually found around the groin, bottom, breasts and armpits. The staging of condition development is the Hurley Staging System (1 being the lowest stage, 3 being the highest stages).

- According to the NHS, the condition affects 1 in 100 people however the numbers are still limited and some incidence rates are unknown
- Affects more women that men [1]
- According to HSdisease, about 93% of people with the condition are between 18-64 years old
- In 2019, researchers in the United and Canada reported 2 peaks for the onset of symptoms:
  - An early-onset group said HS symptoms began in their mid-teen years
  - A late-onset group said HS symptoms began in their mid-40s [2]
- A lump forms as a result on blocked hair follicles
- Sex hormone involvement during puberty (associated symptoms are acne and increased hair growth- hirtuism)
- In rare cases, can be caused by Crohn’s disease (irritable bowel disease) [1]
Medical Students
- Follicular occlusion is the primary initiating event in HS.
  - Triggered by keratosis and hyperplasia of the follicular epithelium.
  - Leads to cyst formation, followed by rupture and inflammation.
- Persistent follicular occlusion causes:
  - Hair follicle dilation, rupture, and release of keratinous contents into the dermis.
  - Results in inflammation, abscess formation, and chronic lesions.
- Immunological factors:
  - TNF-α and other cytokines contribute to chronic inflammation.
  - TNF-α inhibitors have shown positive treatment outcomes.
- Genetic factors:
  - Loss-of-function mutations in γ-secretase complex subunits affect follicular integrity and Notch signaling.
- Proposed contributing mechanisms:
  - Dysfunction in follicular skin immunity.
  - Microbial overgrowth and exaggerated immune responses to commensal flora.
Patients
- HS starts when hair follicles get blocked, causing swelling and cysts.
  - This happens because of too much keratin (the protein that makes up skin, hair, and nails) and skin overgrowth around hair roots.
- These blocked follicles:
  - Burst open and spill into the skin.
  - Cause painful lumps, swelling, and infections.
- The immune system plays a key role:
  - It overreacts to normal bacteria on the skin.
  - This leads to ongoing inflammation.
- Genetics may also contribute:
  - Some people have changes in their genes that affect how their skin repairs itself.
- Overall, HS is caused by:
  - Blocked hair follicles
  - An overactive immune system
  - Possibly inherited genetic issues
- Family history
- Obesity
- Smoking
- Metabolic syndrome (eg. diabetes, high blood pressure, obesity)
- Thyroid diseases (eg. hyperthyroidism, cushing’s disease)
- Joint disease (eg. rheumatoid arthritis)
- Long term inflammation of the skin
- Pyoderma gangrenosum- an inflammatory skin disease that causes painful skin lumps or open sores (ulcers)
- Psoriases- red, scaly infection of the skin
- Vitiligo- condition that causes pathces of depigmentation
- Axial spondyloarthritis- arthritis in the spine and pelvic joints
- Inflammatory bowel disease
- Polycystic ovary syndrome- a condition that causes irregular periods and increased hormone (androgen) levels in the blood
- Squamous cell carcinoma- a common form of cancer [2]
- Boil- like lumps
- Blackheads (open comedones)
- Cysts
- Scarring
- Pus filled lumps
- Fresh-coloured lumps
- Sinus tracks (channels formed in the skin that leak pus)
- Itchiness
- Pain [1]
- History taking from symptoms and family history
- Examine the skin for boils/lumps in locations typically found on the body
- Potentially rule out differential diagnosis with blood and fluid samples from the lumps. [4]
- Folliculitis (inflammation of the follicles)
- Furuncle/carbuncle- abscesses caused by the staphylococcal infection
- Giant comedones- type of cyst with a blackhead-like opening
- Can also be mistaken for severe forms of acne, Crohn’s disease and syphilis [5]
Medical Students
- Staging using Hurley system guides treatment decisions:
  Hurley Stage 1 – Mild:
  - Inflammatory nodules without sinus tracts or scarring
  - Treatment:
    Topical clindamycin
    Intralesional corticosteroids
    Oral antibiotics
  Hurley Stage 2 – Moderate:
  - Recurrent abscesses, sinus tracts, and scarring
  - Treatment:
    Prolonged course of oral antibiotics
    Minor surgical interventions: drainage, unroofing, or punch debridement
  Hurley Stage 3 – Severe:
  - Widespread disease with multiple sinus tracts, scarring, and abscesses
  - Treatment:
    Biologics: Infliximab or Adalimumab
    Wide surgical excision
    Surgical repair and grafting if needed
- Lifestyle and supportive care:
  - Maintain hygiene and reduce mechanical trauma
  - Support mental health due to psychosocial impact
  - Dietary modification: avoid high-glycaemic foods (e.g., white bread, chips, cakes)
Patients
- HS is treated differently depending on how severe it is, using a system called Hurley stages:
  Hurley Stage 1 – Mild:
  - Small painful lumps without tunnels or scars
  - Treatment:
    Antibiotic cream (topical clindamycin)
    Steroid injections into the lumps
    Antibiotic tablets
  Hurley Stage 2 – Moderate:
  - Repeated infections with tunnels and some scarring
  - Treatment:
    Longer course of antibiotic tablets
    Small procedures to clean or remove infected skin
  Hurley Stage 3 – Severe:
  - Many painful areas, deep tunnels, scarring and pus-filled lumps
  - Treatment:
    Strong medicines to reduce inflammation (e.g. infliximab, adalimumab)
    Surgery to remove damaged skin
    Skin repair or grafting may be needed
- Self-care and lifestyle tips:
  - Keep skin clean and dry
  - Avoid tight clothes or anything that irritates the skin
  - Get support for mental health
  - Eat a low-sugar diet (avoid white bread, cakes, chips) [6]
- Can affect the skin or the body with systemic complications
- Skin
  - Sinus tracts
  - Fistulae
  - Scarring
  - Contractures
  - Squamous cell carcinoma
  - Lymphedema (swelling of tissues due to fluid retention in the vessels that hold lymph)
- Systemic
  - Chronic (long term) pain
  - Systemic amyloidosis (disorder that is caused by amyloid being deposited in an organ in the body)
  - Anaemia (low blood cell count) [7]
- Hidradenitis suppurativa is contagious
- It can be spread through sexual intercourse
- It is a severe form of acne
- It is caused by poor hygiene
- It only impacts women [8]
- All patients with the condition will then experience a severe disease [9]
- What can I do to deal with a symptoms flare up (eg. leaking pus)?
- How long does treatment last/ take to be effective?
- How can I prevent complications for occuring?
- Will any underlying conditions I take medication for have to be changed with treatment for HS?
- HSDisease.com
- American Academy of Dermatology
- The Mighty
- NHS
[1] https://www.nhs.uk/conditions/hidradenitis-suppurativa/
[2] https://hsdisease.com/statistics
[3]https://www.sciencedirect.com/science/article/pii/S0190962215019933#:~:text=Capsule%20Summary&text=The%20primary%20trigger%20in%20hidradenitis,occlusion%20of%20the%20hair%20follicle.&text=Inflammatory%20events%20occur%20after%20follicular%20rupture%20followed%20by%20a%20subsequent%20immune%20response.
[4] https://www.niams.nih.gov/health-topics/hidradenitis-suppurativa-hs/diagnosis-treatment-and-steps-to-take#:~:text=Diagnosis
[5] https://onlinelibrary.wiley.com/doi/10.1002/9781119424291.ch12
[6] https://www.msdmanuals.com/en-gb/professional/dermatologic-disorders/acne-and-related-disorders/perioral-dermatitis
[7] https://pubmed.ncbi.nlm.nih.gov/28538749/
[8] https://www.healthcentral.com/slideshow/9-ways-to-live-better-with-hs
[9] https://www.hs-foundation.org/6-myths-about-hidradenitis-suppurativa