Update on hidradenitis suppurativa: connecting the tracts

Abstract

Hidradenitis suppurativa (HS) is a debilitating skin disease characterized by recurrent abscesses, sinus tract formation, and scarring. Prevalence estimates range from 0.053% to 4.1%, although HS is likely an underdiagnosed disease. Although the first reports of HS date back to the mid-19th century, the disease continues to plague patients and physicians desperate for a definitive treatment. Advances in the understanding of the disease process include the possibility of a defective basement membrane at the sebofollicular junction of the folliculopilosebaceous unit (FPSU; that is, where the sebaceous gland empties into the hair follicle) as an initiating event followed by secondary bacterial colonization. New evidence suggests that bacteria living in a community, known as a biofilm, rather than single planktonic bacteria in HS lesions may explain why HS can be resistant to current antibiotic treatment regimens. Available treatment options have expanded to include triple-antibiotic therapy, tumor necrosis factor (TNF-α) and interleukin-1 (IL-1) inhibitors (biologics), laser therapy, and surgical excision, including the skin tissue-sparing excision with electrosurgical peeling procedure. Despite the array of treatments available, many patients continue to struggle with the embarrassment, pain, odor, and frustration that accompany this often isolating disease. Physicians should address comorbidities in HS, including the psychosocial issues patients with HS frequently encounter. Patients can be directed to HS support groups, where they can openly discuss their frustrations, share their experiences in dealing with HS, and band together to advocate for themselves. HS is misunderstood by both patients and physicians, often resulting in a delay in clinical presentation and diagnosis. Patients and physicians across multiple specialties must work together to expand awareness of and interest in HS, so that one day, individuals with HS can be freed from this crippling disease.

Figure 1.. Hurley stages I to III

(a) Hurley stage I, right groin and labia majora: recurrent abscesses without sinus tract formation. (b) Hurley stage II, right axilla: multiple sinus tracts separated by normal skin. (c) Hurley stage III, left axilla: multiple interconnected sinus tracts without normal skin in between.

Figure 2.. Images of latent classifications 1 to 3

(a) Latent class 1 (axillary-mammary), bilateral inframammary areas: recurrent abscesses and comedones with post-inflammatory hyperpigmentation in an obese patient with axillary, mammary, and groin involvement. (b) Latent class 2 (follicular), right posterior helix: multiple open and closed comedones occurring in an atypical location. (c) Latent classification 3 (gluteal), bilateral buttocks: follicular papules and abscesses with post-inflammatory hyperpigmentation in a patient with normal body mass index.