skin health

Hidradenitis Suppurativa

Generality

The suppurative hydrosadenite, or more simply hydrosadenite, is a chronic disease of the skin, on which the formation of subcutaneous nodules is very painful and capable, over time, of causing skin wounds with unpleasant consequences.

Although the subject of numerous investigations, the causes of suppurative hydrosadenitis are unknown.

Currently, there are no specific instrumental or laboratory tests for the detection of hydrosadenite; therefore, to diagnose the latter, doctors can only rely on physical examination and medical history.

From the suppurative hydrosadenite it is not possible to heal; however, different treatments are available, both pharmacological and surgical, which allow to control the symptomatology and improve, in an excellent way, the standard of living of the patients.

What is Suppurative Hydrosadenite?

The suppurative hydrosadenite, or reverse acne or more simply hydrosadenite, is a chronic disease of the skin, which presents the peculiarity of causing, in some specific regions of the human body, small subcutaneous nodules, often swollen and almost always painful due to a process inflammatory at their expense.

The suppurative hydrosadenite acts in a localized manner; to be precise, it has a preference for the armpits, the region just below the breast, the groin, the genital area, the area between the buttocks and, finally, the perianal region .

Suppurative hydrosadenitis is a very unpleasant and annoying disease for at least two reasons, which are: its chronicity and the unstoppable tendency to worsen over time.

Did you know that ...

To describe for the first time the suppurative hydrosadenite was Alfred Velpeau between 1833 and 1839.

Epidemiology

Suppurative hydrosadenitis is an uncommon disease; according to statistics, in fact, it would affect between 1% and 4% of the general population.

Studies of the most affected sex have shown that suppurative hydrosadenitis affects women three times as often as men.

The onset of suppurative hydrosadenitis generally occurs at a young age ( puberty ); cases of hydrosadenitis in adulthood are very rare (especially in people over fifty).

Causes

The suppurative hydrosadenite appears after a particular process of obstruction and inflammation of the hair follicles present in the axilla, just below the breast, in the groin area, in the genital region, in the perianal region or between the buttocks. Despite numerous studies on the subject, the causes of the aforementioned obstruction and inflammation process are a mystery and this means that it is not clear what triggers suppurative hydrosadenitis.

Some theories related to the causes of suppurative hydrosadenitis

In an attempt to understand the causes of suppurative hydrosadenitis, doctors and experts in the field have come to suspect that, at the origin of the condition in question, there may be:

  • Genetic factors . The idea that suppurative hydrosadenitis may have a genetic-hereditary basis derives from its frequent observation in several people of the same family nucleus (therefore in person who have at least a part of the genetic makeup in common).
  • Hormonal factors . The researchers attribute a causative role to the excess of androgen hormones, as they observed that, in women, the symptomatology worsens just before menstruation and after pregnancy (ie two periods characterized by an increase in circulating androgen levels), while it improves during pregnancy and after menopause (ie two periods in which, for different reasons, androgen production decreases).
  • Abnormal immune system responses . The idea that the malfunctioning of the immune system may play a role derives from the frequent detection of suppurative hydrosadenitis in patients suffering from some autoimmune disease (eg, Crohn's disease).
  • Environmental factors . Several studies have shown a connection between suppurative hydrosadenitis and conditions such as obesity, smoking or the use of oral contraceptives.

Risk factors of hidradenitis suppurativa

For reasons that are still unknown, factors such as juvenile age, female sex, a family history of hydrosadenitis, metabolic syndrome, diabetes, arthritis, severe acne, the obesity, inflammatory bowel disease (eg, Crohn's disease), cigarette smoking and the habitual use of deodorants.

Some certainties on the causal origin of the suppurative hydrosadenite

Among the numerous doubts surrounding the causes of suppurative hydrosadenite, there are also some certainties, which are:

  • Hydrosadenite certainly has no infectious origin. Therefore, it is not due to bacteria, viruses or fungi;
  • The suppurative hydrosadenitis is not subject to sexual transmission;
  • Hydrosadenite is not contagious and is not linked to bad personal hygiene.

Symptoms and Complications

The suppurative hydrosadenite always begins with causing a small number of those subcutaneous nodules mentioned at the beginning; after which, as time goes by, the nodules in question increase in quantity, occur in other anatomical areas at risk, become increasingly painful and, finally, acquire new connotations (inducing a general worsening of the symptom picture).

The suppurative hydrosadenite tends to start in a certain area of ​​the body (eg, armpit) and, over a period of time, to spread elsewhere, always obviously in anatomical regions predisposed to it (eg groin, genital area, etc.).

Characteristics of the nodules of the suppurative hydrosadenite

The painful nodules that characterize the suppurative hydrosadenitis can have several peculiarities:

  • They can present themselves as simple swelling of the skin . In general, they have this aspect at the beginning of hydrosadenite;
  • They can be combined with the formation of black skin dots . These are isolated or multiple dots;
  • They can look like red, itchy papules . Typical signs of advanced hydrosadenite, these papules can break and emit a sort of foul-smelling pus;
  • They can evolve into pustules, pseudo-cysts or abscesses ;
  • In a certain region (eg: armpit), they can interconnect at the subcutaneous level, through a series of tunnels or tunnels . These tunnels / tunnels are, in fact, skin wounds, whose healing is very slow and which determine the emission of pus and other similar material.

The phases of the suppurative hydrosadenite

On the basis of how the symptomatology evolves, the suppurative hydrosadenitis can be divided into three phases of increasing gravity, very simply distinguished with the terms " phase 1 ", " phase 2 " and " phase 3 ".

Phase 1 of the suppurative hydrosadenite corresponds, in fact, to the beginnings of the disease in question; to characterize its presence is the sporadic formation of isolated or multiple nodules which are only slightly painful.

Phase 2 of suppurative hydrosadenite is the intermediate pathological phase; it is characterized by the recurrent formation of isolated or multiple nodules, whose correlated pain is decidedly superior to that found in phase 1.

Finally, phase 3 of the suppurative hydrosadenite constitutes the final phase of the current condition as well as the most serious phase; as it flows, the patient repeatedly develops multiple nodules in several anatomical areas at risk, nodules from which pus often emerges and which are interconnected to each other at the subcutaneous level.

Did you know that ...

The suppurative hydrosadenitis has the worst effects in anatomical areas where the skin is subject to continuous rubbing, or with clothes (especially if they are too tight) or with an area of ​​the adjacent body (eg: the groin area of ​​the inner thigh or the armpit).

Complications of the suppurative hydrosadenite

The suppurative hydrosadenite in the advanced phase can be cause of:

  • Skin infections in the nodules . To favor them are the breaking of the latter and the consequent emission of pus;
  • Scars and other skin alterations . These are due to the subcutaneous interconnection process that distinguishes the multiple nodules of phase 3 of the disease;
  • Limitation to arm movements . It may depend on severe pain in the axilla produced by the nodules or, in the more advanced stages, by an excess of scar tissue;
  • Obstacle to proper lymphatic drainage . Many of the anatomical regions on which suppurative hydrosadenitis acts are home to important amounts of lymph nodes (eg, axillary lymph nodes); the scar tissue deriving from the nodules can compromise the proper functioning of the aforementioned lymph nodes and profoundly compromise lymphatic drainage in the anatomical regions concerned;
  • Depression and social isolation . The skin changes due to suppurative hydrosadenitis are sometimes so profound that the patient feels uncomfortable in front of other people and is ashamed of his condition.
  • Skin tumors of the type of spinocellular carcinoma (or squamous carcinoma ). Although it happens very rarely, nodules produced by suppurative hydrosadenitis in the advanced phase can become malignant tumors.

As readers will certainly have deduced, the possible complications of suppurative hydrosadenitis profoundly affect the patients' quality of life.

When should I go to the doctor?

Suppurative hydrosadenitis is a disease whose recognition and timely treatment allow better control of symptoms and complications, even in the most advanced stages.

That being said, an individual with hydrosadenitis should contact their doctor immediately when:

  • The pain in the affected areas is very intense;
  • The pain does not appear to decrease within a couple of weeks;
  • Despite the planned therapy, the entire symptomatology remains;
  • The anatomical areas of interest increase (eg: from a hydrosadenite confined to the armpits to a hydrosadenitis involving armpits and groin);
  • The formation of nodules becomes more and more frequent.

Diagnosis

Currently, there is no instrumental or laboratory test capable of detecting the presence of suppurative hydrosadenite; for the diagnosis of the latter, therefore, the doctors can do nothing but rely on the information coming from the objective examination and the anamnesis, relative to the symptomatology, and proceed by exclusion (the so-called differential diagnosis ).

Physical examination and medical history

In a context of suppurative hydrosadenitis, the physical examination and anamnesis consist substantially in a critical evaluation of the symptoms; in addition to careful observation of the signs on the patient's body, they include questions related to:

  • The symptomatology (eg: when did the first symptoms appear? The symptoms arose after a particular event? Etc.);
  • The state of general health (these are questions focused on identifying those conditions usually related to the presence of suppurative hydrosadenitis, such as metabolic syndrome, diabetes, etc.);
  • Family history (they are questions aimed at discovering whether, in the patient's family, there are other subjects with the same symptoms, such a research explains the possible genetic-hereditary nature of hydrosadenite).

Differential diagnosis

Within the diagnostic pathway that leads to the identification of suppurative hydrosadenitis, the differential diagnosis consists, mainly, in blood tests, performed to exclude that the current symptoms may depend on some infectious disease.

Did you know that ...

The term differential diagnosis indicates the diagnostic approach that allows the identification of a pathology, through the exclusion of all those with similar symptoms and signs; exclusion that can occur through instrumental and laboratory tests.

Therapy

Currently, suppurative hydrosadenitis is an incurable disease, that is, from which it is impossible to cure; however, thanks to some symptomatic treatments, developed in recent decades, the carriers of this unpleasant disease have the precious opportunity to control the main symptoms, slow down their progression and prevent their complications (or a good part of them), sometimes even with surprising results .

The symptomatic treatments in question are more than one and, it must be specified right from the start, not all of them lend themselves to every patient (in the sense that, for some patients, certain treatments are contraindicated).

Before seeing in detail what the symptomatic treatments for suppurative hydrosadenitis consist of, it is good to underline a concept already expressed in part previously: the symptomatic therapy of hydrosadenite is all the more effective, as soon as its planning and its mass take place practically.

Pharmacological symptomatic treatments

The drugs used to control the symptoms of suppurative hydrosadenitis include:

  • Antibiotics with oral or topical administration . They are not used as much for their antibacterial powers (hydrosadenite has no bacterial origin), but for their anti-inflammatory properties.

    Examples: tetracycline, clindamycin, erythromycin, limeciclina, doxycycline, minocycline and rifampicin.

  • Retinoids . Ideal for acne, these medicines are of some use only for some individuals with hydrosadenite.

    Examples: isotretinoin and acitretin.

  • Oral or injectable corticosteroids . They are effective anti-inflammatories, whose prolonged (or inadequate) use can cause several adverse effects, some even very serious.

    The use of injectable corticosteroids involves injecting these drugs directly where there are nodules.

    Examples: prednisone and prednisolone.

  • Immunosuppressants . They are medicines that act on the immune response, making it less powerful. They are useful in those cases of hydrosadenitis in which the disease seems connected to an alteration of the immune system.

    Examples: azathioprine, cyclosporine, infliximab and adalimumab.

  • Contraceptives (hormonal therapy) . They find employment in female patients, which demonstrate a worsening of symptoms in specific phases of the menstrual cycle.

    They are contraindicated in pregnant women.

    Examples: combined birth control pills (or estroprogestinica) and progestin pill (or mini-pill).

  • Powerful analgesics . They serve to mitigate pain when this is intolerable.

    Examples: fentanyl (synthetic opioid), codeine and derivatives, gabapentin and pregabalin.

Symptomatic surgical treatments

The use of surgery in the presence of suppurative hydrosadenitis occurs in the most critical circumstances. For example, it occurs when drug treatments are completely ineffective; when the disease continuously causes multiple nodules; when the nodules, by dint of recurring, have profoundly altered the skin tissues; when the wounds resulting from the nodules are very painful and at high risk of infection.

Among the various surgical procedures that can be adopted in the case of suppurative hydrosadenitis, are:

  • The operation of incision and surgical drainage of the nodules;
  • Laser ablation of nodules and subcutaneous interconnections (tunnels or tunnels);
  • The curettage of the nodules, followed by the deroofing (" uncovering ") of the tunnels / tunnels;
  • The so-called punch debridement for the elimination of single nodules;
  • Removal of the affected tissues by electrosurgery ;
  • Total surgical removal of the affected tissues;

Home remedies and lifestyle

In addition to the aforementioned therapeutic approaches, patients with suppurative hydrosadenitis can benefit from some "home remedies" and the adoption of a healthy lifestyle.

As far as home remedies are concerned, we highlight: the washing of wounds with antiseptic soaps, the application with pain-relieving purposes of wet and hot compresses on the affected areas, the use of loose and comfortable clothes (tight-fitting clothes worsen the symptoms) and the renunciation of the use of any type of deodorant (even these, like tight-fitting clothes, worsen the symptoms).

As for healthy lifestyles, on the other hand, behaviors such as: weight control (if there is an obesity problem), smoking cessation (if there is a smoking problem) and practice deserve to be mentioned. constant physical activity .

Prognosis

Recalling that the suppurative hydrosadenitis is not cured, the prognosis for this annoying disease depends mainly on two factors, which are: early diagnosis and timely implementation of an ad hoc symptomatic treatment.

In practical terms, what has just been said means that a less poor prognosis of hydrosadenitis is when the patient undergoes all the appropriate therapies from the beginning of the condition in question.

Prevention

The lack of information regarding the causes of suppurative hydrosadenitis makes this disease an impossible condition to prevent.