Chronic recurrent follicular occlusive disease of intertriginous areas with painful nodules, abscesses, sinus tracts, and scarring.
Overview A chronic, recurrent, inflammatory follicular occlusive disorder presenting with painful deep-seated nodules, abscesses, sinus tracts, and dermal scarring in intertriginous areas (axillae, inguinal, gluteal, inframammary, perianal).
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Risk factors Smoking (90% of patients are current or former smokers) — strongest modifiable risk factor Obesity (mechanical friction, hormonal milieu) Family history (~30%) — autosomal dominant with variable penetrance in some kindreds (γ-secretase mutations) Female sex; menstruation may worsen flares Metabolic syndrome, type 2 diabetes, PCOS Acne, inflammatory bowel disease (Crohn > UC), spondyloarthropathy associations Pathophysiology Follicular hyperkeratinization and dilatation in apocrine gland-bearing skin → follicular occlusion → rupture into dermis → robust neutrophilic inflammation, sinus tract formation, and scarring. NOT a primary apocrine gland disease (older name 'apocrinitis' is incorrect). TNF-α, IL-17, IL-1β drive inflammation; γ-secretase / Notch pathway implicated in familial forms.
Clinical presentation Symptoms Painful recurrent nodules and abscesses, often draining purulent foul-smelling discharge Pruritus, burning, stinging Sleep disturbance, dyspareunia, gait disturbance, work absences Significant pain — worst-rated chronic dermatologic disease in quality of life surveys Signs / physical exam Primary lesions: tender, deep-seated, dermal/subcutaneous inflammatory nodules and abscesses Secondary lesions: open comedones (double-headed 'tombstone' comedones — pathognomonic), sinus tracts (interconnecting tunnels), hypertrophic and atrophic scars, contractures, lymphedema Distribution: axillae (most common), inguinal folds, perianal/perineal, buttocks, inframammary, submammary; less commonly nape, retroauricular, scalp Lesions tend to be bilateral and symmetric Hurley staging (clinical): • I: solitary or multiple abscesses, NO sinus tracts or scarring • II: recurrent abscesses with sinus tracts and scarring, separated by normal skin • III: diffuse or near-diffuse involvement, multiple interconnected sinus tracts and abscesses across entire area Classic findings Recurrent abscesses + sinus tracts + bridged scarring in axillae and groin; double-comedones.
Differential diagnosis Cutaneous abscess / furunculosis — Single acute abscess, not recurrent in same site, no sinus tracts; staphylococcalCystic acne / acne conglobata — Comedones present (HS lacks except 'double comedones'), trunk/face distributionCrohn disease (metastatic / fistulating) — Perianal fistulas + GI symptoms; can overlap with HSPilonidal disease — Sacrococcygeal area, with hair tuft; not symmetric or multifocalGranuloma inguinale (donovanosis) — Genital ulcers, slow growth, geographic exposure; Donovan bodies on smearLymphogranuloma venereum — Groove sign with bubo formation; serotype L1-L3 chlamydiaSteatocystoma multiplex — Multiple small cysts on chest/axillae, no inflammation or sinus tractsActinomycosis — Chronic sinus tracts with 'sulfur granules'; Actinomyces israeliiDiagnostic workup Diagnostic criteria All three required (Dessau criteria): (1) typical lesions (nodules, abscesses, sinus tracts, scars), (2) typical locations (intertriginous), (3) chronic relapsing course.
Labs Clinical diagnosis — no required labs CBC, CRP, ESR (elevated during flares) Bacterial culture if secondary infection or atypical presentation (cultures often polymicrobial or sterile; routine antibiotics target empirically) Screen comorbidities: metabolic syndrome (lipid panel, HbA1c), depression Skin biopsy in atypical cases; rule out Crohn-related disease Imaging Ultrasound (high-frequency) — assesses sinus tract extent, often used to plan surgery MRI for complex perineal/perianal disease and Crohn overlap Sinography in selected presurgical cases Diagnostic algorithm Hurley Stage Clinical Features Preferred Therapy I (mild) Solitary/multiple abscesses; NO sinus tracts/scarring Topical clindamycin; doxycycline; antiseptic washes; lifestyle II (moderate) Recurrent abscesses + sinus tracts/scars, separated by normal skin Clindamycin + rifampin; adalimumab/secukinumab; localized excision/deroofing III (severe) Diffuse interconnected sinus tracts and abscesses Biologic therapy + wide local excision; multidisciplinary care
Hurley staging of hidradenitis suppurativa and preferred therapy. Treatment First-line Lifestyle: smoking cessation (most impactful intervention), weight reduction, loose breathable clothing, avoid friction/shaving Daily antiseptic wash: chlorhexidine 4%, dilute bleach baths, benzoyl peroxide 5-10% Topical clindamycin 1% solution BID for mild Hurley I disease Hurley I-II: oral tetracycline antibiotic — doxycycline 100 mg BID × 12 weeks (anti-inflammatory dose) OR minocycline Hurley II refractory or moderate-severe: combination oral clindamycin 300 mg BID + rifampin 300 mg BID × 10-12 weeks Biologic therapy (Hurley II-III or refractory): adalimumab 160 mg loading → 80 mg week 2 → 40 mg weekly (FDA-approved); secukinumab (FDA-approved 2023); bimekizumab (recent approval) Hormonal therapy in women: combined oral contraceptive (anti-androgenic — drospirenone/EE), spironolactone 50-200 mg/day, metformin Intralesional triamcinolone 5-10 mg/mL for individual acute nodules Pain control: acetaminophen, NSAIDs, gabapentin/pregabalin for neuropathic component; avoid chronic opioids Severe Hurley III / extensive sinus disease Wide local excision of involved areas with secondary intention healing or split-thickness grafting — definitive for Hurley III in affected region Deroofing of sinus tracts (preferred over excision when possible) Combine with biologic therapy preoperatively to reduce inflammation Multidisciplinary care: dermatology, plastic surgery, pain, mental health Acute abscess Incision and drainage for relief (recognize recurrence is the rule; not curative) Intralesional triamcinolone immediately after I&D Punch debridement of inflamed nodules Second-line / adjunct Oral retinoids: acitretin or isotretinoin (limited evidence for HS but used in some) Dapsone, colchicine, zinc supplementation (limited evidence) Cyclosporine, methotrexate for refractory cases JAK inhibitors (upadacitinib) — emerging data Laser hair removal (Nd:YAG) reduces follicular occlusion in affected sites Complications Severe pain, depression, suicidality (rates exceed other chronic dermatoses) Sexual dysfunction, infertility (genital scarring) Lymphatic obstruction, lymphedema Fistulas to urethra, bladder, rectum Cutaneous squamous cell carcinoma in long-standing perianal/buttock disease (~3% lifetime, often aggressive) Anemia of chronic disease, hypoproteinemia Cardiovascular disease (independent risk factor), metabolic syndrome PANCE pearls Recurrent painful boils in the axillae or groin = HS until proven otherwise; not 'staph infections.' Smoking cessation is the single most impactful lifestyle intervention — strongly counsel at every visit. Double-headed open comedones in affected areas are pathognomonic. Antibiotics work via anti-inflammatory mechanisms, not antimicrobial — failure to respond does not mean culture-directed therapy is needed. Long-standing perineal/buttock HS carries a real risk of cutaneous SCC — biopsy any chronic non-healing lesion. References USCMS 2019 — North American Clinical Management Guidelines for Hidradenitis Suppurativa (Alikhan et al., J Am Acad Dermatol 2019)EHSF 2019 — European S1 Guideline for the Treatment of Hidradenitis Suppurativa (Zouboulis et al., J Eur Acad Dermatol Venereol 2015; updates ongoing)AAD 2024 — Joint AAD-HS Foundation Clinical Care Updates on Biologics and Surgical Options
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