Understanding Hidradenitis Suppurativa

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Hidradenitis suppurativa is a chronic skin disease associated with severe symptoms and complications. Early diagnosis and treatment can improve disease control and overall quality of life. Robert G. Micheletti, MD, discusses the impact of the disease and provides insight on its optimal management.

Robert G. Micheletti, MD: Hidradenitis suppurativa (HS) is a condition that affects the hair follicle oil gland unit in the body, and essentially what happens is you have a follicular occlusion of those units, sometimes a cyst formation, and then cyst rupture. And due to a variety of inflammatory mediators—bacteria, other things that play a role—you get follicular rupture and then ensuing inflammation, scarring, and other symptomatology that the patient experiences in the form of drainage, pain, and swelling. In terms of how common it is, it is anywhere between less than 1% and 4% based on the literature. I usually tell my patients it’s around 1% of the population, which doesn’t sound like a lot. But when you think about how many people there are out there, it is quite a few patients who have hidradenitis.

For patients who have hidradenitis, I think it’s very important, when you’re discussing with a patient, to acknowledge things that they’re dealing with. HS can have quite a spectrum of severity, ranging from mild to quite severe. But, even mild hidradenitis I feel compelled to almost say in quotation marks because these lesions are painful, they’re messy, and there’s often an odor associated with them.

And so, even patients with fairly mild hidradenitis are really suffering a lot with this condition. It affects things like the ability to hold down a job, so if you have perineal disease and you can’t sit for prolonged periods, that’s an issue. Sexual health, as well, is impacted in issues of intimacy. And then, not surprisingly, patients have a high rate of depression and anxiety associated with this condition, such that you really, in treating a patient, have to pay attention to that. Pay attention to those issues. When you’re trying to get a patient to adhere to a medical regimen, I think it’s very helpful to state out loud that these are important issues that they’re dealing with.

In addition to that, there’s literature that shows that patients with hidradenitis have any number of other comorbidities quite commonly. Obesity is certainly associated and high rates of smoking. Those two are possibly important for the pathogenesis of hidradenitis. But, beyond that, things like diabetes, cardiovascular disease, there are more and more papers coming out discussing the risk of cardiovascular adverse outcomes in patients with hidradenitis, akin to the literature that has come out about psoriasis.

So, patients with HS probably have as much, if not more, of a cardiovascular risk as patients with severe psoriasis. When you’re getting a patient in your clinic with HS, certainly there’s a lot to be dealing with, and addressing, with respect to their skin. But, it’s also important to be thinking about these other really critical comorbidities, psychosocial issues, and other areas of health that could be addressed and should be addressed. I really look at it as an opportunity to get somebody into treatment, not just for their skin disease, but for those other things, as well.

Hidradenitis suppurativa can have a number of complications. We’ve spoken a little bit about the comorbidities that are associated with it, but talking specifically about the physical complications that can occur: in general, we think about things like boils or abscesses, so these are painful, these are messy, these create odor. Those are things that sometimes will bring patients to the ER, and very frequently before they have a diagnosis of hidradenitis suppurativa, they’re coming to the ER with what they think are boils or staph abscesses. That will lead to things like incision and drainage and other painful procedures that they undergo.

In more advanced disease, you get scar formation and what we refer to as sinus tract formation, where you have these fibrous cords under the skin where if you press one side, you’ll get pus coming out of a totally separate area. And, as you could imagine, that’s something that, over time, worsens in moderate and severe disease and builds on itself to the point where patients, even once they’re getting into treatment, they’re still having this kind of drainage and pain going on because of the scar that’s already occurred.

And, occasionally, we have patients with such severe disease, where even range of motion, ability to raise the arm, ability to sit, to move around, certainly to exercise, all of those things are impacted. I’ve had patients that I’ve had to refer even to orthopedic surgery to work on joint mobility, frozen shoulders, and things like that. Physical therapy can also be very important for some of those patients. Even if you set aside all the important comorbidities that we see with these patients, just the disease by itself has these physical implications for day-to-day activities, sexual health, etc.