Hidradenitis Suppurativa

My senior year in high school I was part of the healthcare tract so earned my nursing assistant certification, then my hospice certification, then became an EMT after graduating high school, to soon after finishing my RN degree, on and upwards for the next thirty years, but it wasn't until about seven or eight years ago that I learned about Hidradenitis Suppurativa. Maybe because the name is just impossible to remember? Maybe because when these present, we think of them as an isolated, infectious lesion? It seems since though, these cases are pretty consistently presenting themselves in my practice and every time I sort of wince inside as I can't imagine the insufferable nature this condition must cause.

Acne in the axillary or even perineal area - severe acne - can you even imagine?! It's actually quite common which is to say that about 4% of women have it (Shah, 2005), about the same number of babies who present in a breech presentation at birth. This diagnosis though often gets overlooked so it is thought that there are far more people suffering from hidradenitis suppurativa than what we understand in the medical literature. In fact, most causes aren't diagnosed until they are moderate to severe (Wark & Cains, 2020). It is four times more likely in women than in men, and it's more common in People of Color. It's painful, disfiguring, and at times really debilitating.

Hidradenitis Suppurativa

Hidradenitis Supprativa is marked by periods of inflammation with occasional secondary infections, and intermittent remissions that can last several years (Shah, 2005). This almost always presents after puberty and before the age of 40 years, leading to the theory that there is a hormonal component to the pathogenesis. Flare-ups are linked to menses, and women who have either shorter cycles or longer duration of menstrual flow seems to suffer with hidradenitis supprativa more often. There is some association to Polycystic Ovarian Syndrome as well.

Hidradenitis Supprativa is an inflammatory condition that targets hair follicles under the skin, chronic auto-inflammatory in fact, not an infection, at least initially. The mainstay of conventional medicine though, is either antibiotics or surgery, offering nothing for the underlying causes.

There also seems to be a genetic component, and in one study of 110 individuals with hidradenitis supprativa, 38% reported someone else in their family also had this disease (Shah, 2005). It's thought then to have an autosomal dominant inheritance. What are the triggers though, that turn on these genetics, and how might we optimize our health to turn off these variant genes, minimizing outbreaks? How might we approach care for these individuals beyond treatment for immediate outbreaks? Let's talk first about more immediate care and then dive into root causes and long-term improvements.

Might I have Hidradenitis Suppurative?

There are no special tricks for diagnosing this condition, no special tests or labs. Your clinician can identify it by examination. Typically this starts with discomfort, itching, redness, burning, and excess sweating (Shah, 2005). Then it becomes tender and the larger, nodular lesions appear. Most often this is in the armpits, but it can occur just about anywhere. I've had clients with these outbreaks in their groin, in their gluteal folds, around the breast or around the umbilicus, even on the ear. These lesions are most frequently in areas where the skin rubs together and where it sweats.

This diagnosis can be a smidge challenging when a single lesions appears, as this can look like other pathologies so determining if hidradenitis suppurative is the right diagnosis may allude your clinician initially. These nodules though have malodorous, superinfected drainage (Shah, 2005). Fever is not common, nor does the infection advance to sepsis, or at least this is super rare. Your clinician may get a culture to help direct treatment.

As this condition progresses though, if at first a bit hard to discern, this becomes more clear as these outbreaks become more frequent, they often leave scars, even fistula tracts and sometimes they simply don't heal entirely (Shah, 2005). Yeah, little wince. Some do have just the occasional outbreak, but others have really significant, painful abscess formations in multiple sites which can lead to painful sinuses that drain, or even indurated, scarred skin or even subcutaneous tissue. Some areas may coalesce to form tender, raised, violaceous dermis. This can become so inflammatory that it causes arthritis or even squamous cell carcinoma, even restriction of limb movement.

When these present in the perianal areas, biopsies are often sent to exclude the possibility of cancer (Shah, 2005). Crohn's disease is another condition your clinician should consider when these cysts are present in the groin, perineal, anal areas. When it's not hidradenitis suppurative, it might be a carbuncle, a dermoid cyst, erysipelas, furuncle, a granuloma, lymphogranuloma, pilonidal cyst, or even tuberculosis of the skin.

What do We Do About It?

There is no cure sadly. However, there are many conventional treatment options and this largely depends on how this disease manifests in each individual, as well as how it is progressing. Oddly enough, while there is a hearty amount of anecdotal information about treatment, there really isn't a lot of scientific review. In one study, 24% of those with hidradenitis suppurative did not find a single treatment effective, even after 19 years of effort (Von der Wert & Williams, 2000). There are also functional approaches, which I'll discuss in a moment, but you'll find these two models see this condition very, very differently.

Why women are more impacted is a little unclear and deodorants, shaving, and depilation have not been shown to relate to diagnosis (Morgan & Leicester, 1982). However, if you find they relate to your outbreaks or inflammation, avoid them. Warm compresses, topical antiseptics, and antibacterial soap may be helpful. This isn't about poor hygiene though, and it isn't contagious (Shah, 2005).

If there is a little extra chub in the armpit though, this can make it worse as underarm adiposity can create that ideal environment for bacterial growth and also increases friction (Shah, 2005). Weight loss can improve symptoms, but it isn't a cure. Minimizing restriction clothing can also help by reducing friction, as well as avoiding synthetic clothing. Flare-ups seem to be worse in the heat and humidity, or when exposed to prolonged heat, so avoid those sorts of climates as you are able. Stress management is also important, because psychosocial stress does play a role.

Conservative measures for treatment are warm baths, hydrotherapy, and topical cleansing agents, even nonsteroidal anti-inflammatory drugs. Antibiotics are often provided, although are not proven effective in these cases (Shah, 2005). If the skin seems infected though, this might be wise. Long-term, suppressive therapy with antibiotics is not supported. The average length one has to endure painful nodules is about 7 days, which is about as long as we treat with antibiotics, giving the perception relief came with a script. Clinicians might base their treatment or prescriptions based on culture results. Topical antibiotics may prove helpful prior to oral antibiotics as well, and reduce systemic impact. Cleocin has been studied and demonstrated effective when applied topically. Antistaphylococcal agents are best for axillary disease, and more broad-spectrum coverage for those in the perianal areas. Dicloxacillin, erythromycin, tetracycline, and minocycline have also been used with some effectiveness. Cephalosporins may be helpful for concurrent active cellulitis. When severe and reoccurring, two months or more of antibiotic therapy may be needed.

Clinicians have tried oral contraceptives with high estrogen-to-progesterone to address a hormonal etiology, and Proscar (5mg daily) has demonstrated effective in case studies (Shah, 2005). In Europe, the antiandrogen cyproterone acetate (Cyprostat) has been successful in some studies, but it isn't approved in the United States. Oral retinoids, like Accutane, have also been used. These medications work by inhibiting sebaceous gland function and abnormal keratinization. This might be especially helpful prior to surgery to reduce inflammation. There are significant side effects with this approach however, including birth defects, hepatotoxicity, pseudotumor cerebri, and aggression.

Corticosteroids and immmuno-suppressants are other treatment possibilities (Shah, 2005). Topical amcinolone (Aristocort) may be an option, but insufficient research has been conducted for it to be recommended routinely. Oral cyclosporine (Sandimmune) has shown some benefit, but chronic treatment has significant risks.

Surgical Treatments

When outbreaks occur, sometimes individuals will have larger, fluctuant abscesses. These can be relieved in the clinic with incision and drainage. However, this is really only short-term relief and really has little impact on the overall course of the disease. When hidradenitis sinus tracks are well established, but relatively superficial, they can be unroofed or laid open (Culp, 1983). Because these tracks are lined by epithelium, the floor of the track can be preserved; this facilitates rapid healing and minimizes scarring (Townsend & Sabiston, 2001).

The literature seems to lean into early, rather than delayed surgical intervention, largely because repeated failed treatments leads to the disease becoming more widespread and severe at presentation, making surgical options more difficult. Having said that, surgery only addresses the present condition, so reoccurrence at a new site is entirely possible. However, one study with 82 patients treated with wide excision found recurrence rates were zero percent for perianal disease, 3% for axillary disease, and 37% for inguinoperineal disease (Harrison et al., 1985).

Obesity, insufficient excision, significant skin maceration, and chronic skin infection may increase the incidence of recurrence. In another study, the overall complication rate was 17.8% (Rompel & Petres, 2000). Most were minor, such as suture dehiscence, postoperative bleeding, and hematoma. The rate of recurrence in this study was 2.5% and was related to the severity of the disorder.

Psychological Support

In addition to treating the physical illness, we must acknowledge the significant impact this condition has on its victims. Because the areas of the body that are affected, along with the malodorous discharge, the chronic discomfort, and the general unsightliness of the disease, hidradenitis suppurativa poses many challenges, especially in their personal or intimate life. Unforgiving societal attitudes regarding inappropriate body odor, as well as years of inadequate treatment, may lead to frustration, depression, and isolation. This is reason enough to consider surgical intervention early.

A Functional Medicine Perspective

If we understand hidradenitis suppurativa as inflammatory and not infectious, and understand that the immune system is targeting the hair follicle, then we think more about immune responses, antimicrobial peptides, glandular secretions, and numbers of sebaceous glands involved in this condition. Studies have suggested that some of these immune abnormalities may be related to imbalances in the microbes that inhabit the skin or the gut (Wark & Cains, 2020). People with hidradenitis suppurativa have an altered balance of the types of bacteria that normally inhabit the skin, even when the skin lesions are not present (Mintoff et al., 2021). For example, they show greater numbers of anaerobic gram-negative bacteria in the skin.

In addition, people with hidradenitis suppurativa have changes in their gut microbiomes which seem to contribute to systemic inflammation that leads to skin lesions via the gut/skin axis (Mintoff et al., 2021). The gut microbiome and its dysbiosis has been implicated in a number of other diseases, such as inflammatory bowel disease, atherosclerosis, autism, and asthma (Wark & Cains, 2020). Intestinal bacteria play a role in immunological signalling, host cell proliferation, intestinal endocrine functions, biosynthesis of hormones, vitamins and neurotransmitters, and dietary and drug metabolism among so much more. It is believed that imbalances in the gut bacteria, also referred to as dysbiosis, potentially influenced by a high-fat diet, elevate inflammatory cystokines, which increase substances that cause changes in the skin, creating skin lesions in susceptible individuals (Mintoff et al., 2021).

We know that hidradenitis suppurativa is more common in women, and those with excessive hair growth, obesity, or issues with insulin and blood sugar balance such as diabetes or metabolic syndrome. Being overweight can increase the amount of contact, sweat retention, and friction in areas of skin that rubs together, like the armpits and groin. Issues with insulin resistance and blood sugar imbalances, as well as certain hormonal changes like a relative androgen excess, may co-occur with obesity or on their own and increase the risk of developing hidradenitis suppurativa. Of course addressing these issues, functionally, may help resolve outbreaks of hidradenitis suppurativa. We'd want to optimize blood sugar balance and insulin function, gut health and the microbiome, food allergies and sensitivities, hormone levels, and vitamin D status in effort to support overall balance in the body.

Blood Sugar and Insulin Balance

Metabolic markers are an important part of evaluating the underlying root cause of hidradenitis suppurativa as obesity and blood sugar imbalances like metabolic syndrome are related. Fasting glucose levels, even a hemoglobin A1c can help evaluate your blood sugar regulation. Insulin can also be evaluated, and c-peptide, a marker that the body is producing insulin. When evaluated together, these tests can help identify insulin resistance.

Gut Health & the Microbiome

The gut and its microbiome has a significant impact on systemic health, as well as skin inflammation, and it plays a role in hidradenitis suppurativa. Functional clinicians will either encourage a gut health protocol such as a 5R Elimination program or testing such as MRT and LEAP therapy. After an initial elimination diet, an anti-inflammatory diet may be helpful or even the Mediterranean diet. You'll want to limit processed foods and additives, caffeine, and alcohol, all which negatively impact health, and can worsen hidradenitis suppurativa symptoms. MRT testing is excellent for eliminating food or chemical sensitivities, and can help improve overall diet so may improve insulin resistance and balance blood sugars.

Gluten sensitivity may play a role as well, even leaky gut so identifying and correcting these issues is part of reducing vulnerability for hidradenitis suppurativa outbreaks (Aboud, et al., 2020). One study, albeit rather small, showed that individuals with hidradenitis suppurativa had serology-identified reactions to brewer's yeast and wheat and their skin lesions improved when following a brewer's yeast-free diet for 12 months.

Various gut health tests may also be helpful. The GI Effects or GI Map can help evaluate the gut, providing information on the variety of microbes inhabiting the gut, as well as understanding of the brush border health so your clinician can guide you towards healing and rebalancing the gut's ecosystem.

Research has shown that diets high in dairy and higher glycemic index foods like white bread, rice cakes, most crackers, bagels, cakes, doughnuts, croissants, and processed breakfast cereals can contribute to the plugging up of sebaceous glands that can lead to the rupture of follicles as occurs in hidradenitis suppurativa (Danby, 2015). When these foods are eliminated, individuals with hidradenitis suppurativa do have improvement. Gluten, dairy, refined sugars, tomatoes, and alcohol seem to be big culprits.

Androgens & Hormones

My favorite hormone testing panel is the DUTCH panel, which is a dried urine test, and it can easily be completed at home. It helps us understand how your hormones are metabolized or broken down, including cortisol. When the gut is out of balance, the hormones are also out of balance, or even if stress overwhelms, hormones will be impacted which can trigger hidradenitis suppurativa.

Vitamin D Levels

Since many with hidradenitis suppurativa are deficient in vitamin D, measuring one's levels can optimize treatment. Understanding vitamin D levels can also help the practitioner better understand, or start to evaluate one's lifestyle as well. Are they getting into nature? Are they active and getting sun on their face? Are they sleeping well, happy, and engaged with life?

Conventional verses Functional Treatments

As shared, conventional medicine approaches treatment largely through antibiotics or surgical treatment, although acknowledges this is an approach that only addresses those lesions currently present, not those into the future. This is important, but it isn't the entirety of how we should approach this condition although it is about all the attention practitioners in conventional medicine have time to address, or even training.

Repeated antibiotics can damage gut health, which may exacerbate reoccurrence. The reality is that hidradenitis suppurativa is not an infectious process in itself. Bacteria doesn't cause these lesions, so a closed, unruptured lesions would most not grow any pathology when cultured. Certainly, once ruptured and bacteria introduced, secondary infection may occur, but the underlying root cause was not infectious; therefore, we need to take a deeper look into causes.

Daily skin care is encouraged, with an antiseptic wash such as chlorhexidine 4% or benzoyl peroxide wash, maybe even a topical retinoid to reduce inflammation, but again, because hidradenitis suppurativa is not infectious, this isn't a hygiene problem. Antibiotics (doxyclinic, clindamycin, rifampin) play a role, but should not be considered the mainstay of treatment. Steroid injections may also be offered for intensely swollen and inflamed sores (triamcinolone acetonide or Kenalog-10), but again, these are not a long term fix.

When this condition is more severe, biologics may be integrated into treatment (Aggarwal et al., 2013). Adalimumab and infliximab are both approved to treat moderate to severe hidradenitis suppurativa, through inhibiting tumor necrosis factors (TNF). Numerous reports have suggested that the production of TNF can be suppressed by curcumin as well. These can improve symptoms within weeks by dampering the immune system. Retinoids are another approach. Surgery may also be necessary, even skin grafting. Addressing the issue at hand is totally appropriate, but don't stop here. Dig deeper.

Imbalances in the immune system that contribute to hidradenitis suppurativa really should be the focus. Gut health. Nutrition. Sleep. Hormones. Eliminating toxins such as quitting smoking. Eliminating or minimizing alcohol. Getting sun on your face. Honoring oneself so that balance is maintained throughout one's day. Making time for rest. Maintain a healthy body weight. Understanding and correcting blood sugar balance. Optimize detoxification pathways. Supplements may even support resolution of hidradenitis suppurativa, such as zinc, turmeric, and vitamin D.

Zinc & Nicotinamide

Zinc plays an integral role in immunity within the skin and has been shown to have an anti-inflammatory effect. Those who have tried 90mg a day of zinc gluconate have had less disease severity, redness and an overall fewer number of inflammatory nodules (Hessam et al., 2016). Another study showed similar improvements when combining zinc supplementation with nicotinamide (Molinelli et al, 2020). Those given 90mg of zinc gluconate with 30mg of nicotinamide orally, once a day, for 90 days had significant improvement in symptoms of hidradenitis suppurativa compared to controls. When long-term zinc supplementation is used, it is important to monitor levels of zinc and copper as well as look for anemia.

Turmeric

Botanical medicine is a huge passion of mine and I've integrated healing herbs into most all of my treatment plans for clients. Turmeric is a medicinal herb from which curcumin is derived. You've probably cooked with turmeric. It's excellent for improving our immune health, modulating our immune cells, so it can help reduce inflammation in particular with the lesions that present in those with hidradenitis suppurativa. There is also evidence that curcumin down-regulates TNF expression in different cell types and in response to a variety of stimuli which suppresses our innate immune response to bacterial infection (Aggarwal et al., 2013). Topical or oral preparations can support skin health, or just about any autoimmune disease or disease of chronic inflammation, and at the same time support metabolic syndrome, diabetes, and obesity.

Vitamin D

Again, vitamin D is integral for supporting immune health and also plays a role in the regulation of skin and hair follicles. We've talked about the evidence demonstrating those with hidradenitis suppurativa often have lower vitamin D levels, or even variants that create change in their vitamin D metabolism, so low levels of vitamin D should be evaluated and corrected (Brandao et al., 2020).

Short and Brief Summary

Hidradenitis suppurativa is a chronic auto-inflammatory condition that causes deep-seated nodules and abscesses in the skin that can progress to draining tracts and fibrotic scars, as well as significant psychological distress. Lesions occur most frequently in areas of the skin that rub together or sweat, such as the armpits, groin and breast areas. Changes in hormones and smoking are significant triggers for outbreak. This disease arises from genetic susceptibility and immune system dysregulation contributing to increased inflammation around hair follicles in the skin.

A conventional approach to treatment utilizes a combination of topical steroids, retinoids, and antibiotics, sometimes systemically. Medications for improving hormonal fluctuations may be utilized or systemic immunomodulators, or even biologics. An integrative approach will address lifestyle, nutrition, and supplementation to help reduce side effects of treatment, but also prevent reoccurrence ultimately improving quality of life.

An elimination diet or MRT testing and then LEAP therapy may offer profound improvements. Integrating an anti-inflammatory or Mediterranean diet after the initial identification of triggers from the elimination diet can be helpful, and address blood sugar imbalances while reducing overall inflammation. Gut Health is integral to healing. Supplementation with vitamin D, turmeric, and zinc may support skin health and help manage inflammation. Connect with me if you'd like to consult and improve your health.

References

Aboud, C., Zamaria, N., & Cannistra, C. (2020). Treatment of hidradenitis suppurativa: surgery and yeast (Saccharomyces cerevisiae) - exclusion diet. Results after 6 years. Surgery, 167(6), 1012-1015.

Aggarwal, B. B., Gupta, S. C., & Sung, B. (2013). Curcumin: an orally bioavailable blocker of TNF and other pro-inflammatory biomarkers. British Journal of Pharmacology, 169(8), 1672-1692.

Alikhan, Ali, Sayed, C., Alavi, A., Nailk, H. B., Orgill, D., & Poulin, Y. (2019). North American clinical management guidelines for hidradenitis suppurative: a publication from the United States and Canadian Hidradenitis Suppurative Foundations. Journal of the American Academy of Dermatology, 81(1), 91-101.

Brandao, L., Moura, R., Tricarico, P. M., Gratton, R., Genovese, G., Moltrasio, C., Garcovich, S., Boniotto, M., Crovella, S., & Marzano, A. V. (2020). Altered keratinization and vitamin D metabolism may be key pathogenetic pathways in syndromic hidradenitis suppurativa: a novel whole exome sequencing approach. Journal of Dermatology Science, 99(1), 17-22.

Culp, C. E. (1983). Chronic hidradenitis suppurativa of the anal canal. A surgical skin disease. Dis Colon Rectum, 26(10), 669-676.

Danby, F. W. (2015). Diet in the prevention of hidradenitis suppurativa (acne inversa). Journal of American Academia Dermatology, 73(5), 2-4.

Harrison, B. J., Kumar, S., Read, G. F., Edwards, C. A., Scanlon, M. F., & Hughes, L. E. (1985). Hidrandenitis suppurative: evidence for an endocrine abnormality. British Journal of Surgery, 72, 1002-1004.

Hessam, S., Sand, M., Meier, N. M., Gambichler, T., Scholl, L., & Bechara, F. G. (2016). Combination of oral zinc gluconate and topical triclosan: an anti-inflammatory treatment modality for initial hidradenitis suppurativa. Journal of Dermatology Science, 84(2), 197-202.

Mintoff, D., Borg, I., & Pace, N. P. (2021). The clinical relevance of the microbiome in hidradenitis suppurativa: a systematic review. Vaccines, 9(10). 1076.

Molinelli, E., Brisigotti, V., Campanati, A., Giacchetti, A., Cota, C., & Offidani, A. (2020). Efficacy of oral zinc and nicotinamide as maintenance therapy for mild/moderate hidradenitis suppurativa: a controlled retrospective clinical study. Journal of the American Academy of Dermatology, 83(2), 665-667.

Morgan, W. P. & Leicester, G. (1982). The role of depilation and deodorants in hidradenitis suppurativa. Arch Dermatol, 118, 101-102.

Rompel, R. & Petres, J. (2000). Long-term results of wide surgical excision in 106 patients with hidradenitis suppurativa. Dermatol Surg, 26, 638-643.

Shah, N. (2005). Hidradenitis suppurativa: a treatment challenge. American Family Physician, 72(8), 1547-1554.

Townsend, C. M. & Sabiston, D. C. (2001). Sabiston textbook of surgery: the biological basis of modern surgical practice (16th ed.). Saunders.

Von der Wert, J. M. & Williams, H. C. (2000). The natural history of hidradenitis suppurativa. Journal of European Acad Dermatol Venereol, 14, 389-392.

Wark, K. J. L. & Cains, G. D. (2020). The microbiome in hidradenitis suppurativa: a review. Dermatologic Therapy, 11(1), 39-52.