Hidradenitis Suppurativa (Acne Inversa): Symptoms & Treatment

Hidradenitis suppurativa is a chronic, scarring skin disease that affects the apocrine glands, also known as the sweat glands. It causes painful lumps and boils on the skin, especially in the armpit, groin, breast, and anus. It is a relatively common condition but is frequently misdiagnosed and can be disabling and distressing for the person affected.

Hidradenitis suppurativa, also known as acne inversa, does not occur before puberty. Rather, most people get it between the ages of 20 and 40 years old. Women are four times more likely than men to be affected.

This article explores the symptoms, causes, diagnosis, and treatment of hidradenitis suppurativa and how to cope if you are affected by this common but little-discussed skin condition.

Hidradenitis Suppurativa Symptoms

Hidradenitis suppurativa develops in areas of the body with sweat glands, such as the armpits, groin, upper thighs, buttocks, scalp, and beneath the breasts in females.

Early symptoms include:

• Pimple-like bumps, although they occur in areas you typically do not find acne
• Blackheads, which tend to develop in pairs
• Painful lumps, sometimes as large as a marble just beneath the skin
• Boils, which can rupture and leak fluid and pus

Hidradenitis suppurativa can look a lot like acne, particularly early on. The two can easily be distinguished by the areas they affect and whether or not the skin issues are symmetrical. If HS affects an area on one side of the body, the same area on the other side is usually also affected. The same is not true for acne.

Symptoms can fluctuate. In mild cases, you might notice just a cluster of two or three blackheads that connect beneath the skin.

Once hidradenitis suppurativa starts, it gets progressively worse. The boils can become very painful and restrict movement. The boils can also rupture and leak fluid, often with a foul odor.

The accumulation of pus beneath the skin can lead to the formation of painful abscesses, which can cause deep and unsightly scars after the tissues have healed. Abscesses can also sometimes merge beneath the skin and cause cord-like scarring.

Types of Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) falls into five broad categories, each differing by appearance, body location, and other factors:

• Regular HS: This is the most common form of the disease. It causes classic HS symptoms, is recurrent, and tends to persist for at least six months.
• Friction furuncle: This is regular HS with the addition of deep boils and abscesses in areas where the skin rubs together.
• Scarring folliculitis: This is regular HS with the addition of boils, tunneling abscesses, fluid-filled cysts, and double-headed blackheads. All of these can lead to significant scarring.
• Conglobata: This is a type of HS that causes cysts and a severe form of acne, called acne conglobata, on the back and face.
• Syndromic: This is a form of HS that occurs as part of a syndrome of diseases, such as PAPASH syndrome (pyogenic arthritis, pyoderma gangrenosum, acne, and hidradenitis suppurativa).

Causes and Risk Factors

The exact cause of hidradenitis suppurativa is disputed. Since it looks similar to acne, some scientists believe that it is caused when hair follicles become blocked with a skin protein known as keratin. Others believe that it is caused by a blockage of apocrine (sweat) glands.

In either case, the blockage of pores causes the formation of bumps and boils than can rupture and become infected. The condition most often affects areas of skin that rub together and have many sweat glands (such as the armpits and groin).

There are certain risk factors that increase the likelihood of hidradenitis suppurativa:

Diagnosis

Hidradenitis suppurativa is diagnosed by a healthcare provider based on its appearance. There are no lab tests or biopsies that establish the diagnosis.

In the early stages, hidradenitis suppurativa resembles isolated boils or infected hair follicles. Symptoms often come and go.

Repeated breakouts are one clue that something beyond just a simple boil or inflamed hair follicle is happening. As breakouts continuously appear and heal, they often form scar tissue, often creating bands of scarring that can restrict the movement of the limb over time. This is another giveaway that the condition is hidradenitis suppurativa.

Many people are embarrassed by the multiple infections, thinking that they have ingrown hairs in sensitive areas, as well as by the smell that leaks out of the breakouts. Due to this embarrassment, they do not go to the healthcare provider until the boils have become numerous or intolerable.

Hidradenitis Suppurativa Treatment

Hidradenitis suppurativa does not ever fully go away. It’s a lifelong condition that must be managed.

Regular hidradenitis suppurativa can go into remission—a period without a flare-up—on its own. Even so, outbreaks tend to be prolonged, generally lasting six months or more.

Treatment by a dermatologist can help minimize the impact and severity of whatever type of HS you have.

That said, treating hidradenitis suppurativa can be difficult. It is best treated in the early stages before extensive scarring develops.

Although prescription medications are central to the treatment of hidradenitis suppurativa, there is evidence that diet and self-care can also improve outcomes. Surgery and specialist procedures are also sometimes used.

Self-Care

Although hidradenitis suppurativa is not associated with poor hygiene, good skincare practices remain essential to treating the disease.

According to the American Academy of Dermatology Association (AADA), it is important to avoid harsh soaps and other skincare products that can irritate the skin. You should also switch to a gentle, fragrance- and paraben-free deodorant or antiperspirant. Instead of soap, use a gentle face wash containing benzoyl peroxide.

Quitting cigarettes is also essential.

Diet

Changes in diet may also help by reducing inflammation that can contribute to the onset or worsening of the disease.

According to the AADA, the Mediterranean Diet may be beneficial to people with hidradenitis suppurativa as it contains foods that are known to be anti-inflammatory, such as:

• Fresh vegetables and fruits
• Whole grains
• Fish
• Seafood
• Beans
• Extra virgin olive oil

On the other hand, foods like red meat, bacon, sugary drinks, diet soda, processed meats (like cold cuts, chicken nuggets, and hot dogs), and other processed food should be avoided if you have hidradenitis suppurativa.

Prescriptions

Antibiotics, biologics, hormone therapy, and a vitamin A derivative called isotretinoin may be prescribed for the treatment of hidradenitis suppurativa.

Antibiotics

Oral antibiotics (those taken by mouth) may help suppress the inflammation, especially in mild cases, although they do not cure the disease. The same antibiotics that are used for acne are used for hidradenitis suppurativa, only in higher doses. These antibiotics include erythromycin, tetracycline, minocycline, and doxycycline.

Topical antibiotics (those applied to the skin) can also be used in cases of mild hidradenitis suppurativa.

Biologics

Humira (adalimumab) was approved by the U.S. Food and Drug Administration (FDA) in 2015 for people ages 12 and older who have moderate to severe hidradenitis suppurativa. It is a biologic agent that helps reduce inflammation.

In 2023, the FDA approved Cosentyx (secukinumab) for the treatment of moderate to severe HS in adults. Cosentyx is an intravenous (IV) infusion that is typically given every 4 weeks.

Hormone Therapy

Some females experience improvement of hidradenitis supportive symptoms when treated with hormone therapy, namely oral contraceptives, Procar (finasteride), and Aldactone (spironolactone).

This is especially true for people who get flare-ups right before their menstrual cycle. It is believed that these treatments balance hormones that contribute to inflammation.

Isotretinoin

Isotretinoin (commonly referred to as Accutane) may be helpful in mild cases, but the response can be unpredictable. It is sometimes used to reduce the size of the affected areas prior to surgery.

Isotretinoin does have significant side effects and must not be used by pregnant women.

Surgery and Specialist-Driven Procedures

When oral medications fail to provide relief of hidradenitis suppurativa, steroid injections may be useful in reducing inflammation. These injections may be especially useful in areas where there is extreme pain.

Steroid injections are normally combined with other treatments and are not used as the sole treatment for hidradenitis suppurativa.

If all other options fail, surgery may be considered. With that said, recurrence is common if only the immediately affected area is treated. Instead, surgeons will typically perform what is called a wide local excision in which the affected tissues and a margin of surrounding normal tissues are removed.

The wound is not stitched back together but left open to heal from the inside out. Skin grafts may be placed in the excised area to speed healing.

Coping

Hidradenitis suppurativa can be a debilitating condition because it can be so painful. Pain can make it difficult to move around, especially if the breakouts occur in the groin or buttocks area.

In addition to the odor, many people also feel embarrassed about discharge leaking onto clothes. This can cause people to isolate themselves, leading to anxiety and depression.

If you have hidradenitis suppurativa, it’s important to seek support, whether it be from friends and family or from local or online support groups.

Let your healthcare provider know exactly how the condition is impacting your life. If you’re in pain, feeling depressed, or your treatment is not working as effectively as it should, let your healthcare provider know. It is only by reaching out that solutions can be found.