Hidradenitis occurs when a plug of dead skin in the duct of a gland emptying into a hair follicle in areas of opposing skin surfaces like the armpits, under the breasts and in the groin initiates an infectious process as bacteria multiply within the plugged gland creating a skin boil. The obstructed gland or boil ruptures into the deep layers of the skin; adjacent glands become involved; and abscesses form. Subsequently, multiple draining sinuses or holes appear on the skin surface and the whole hair bearing area may become inflamed. We call this process Hidradenitis Suppuritiva (HS).
As I described my first choice of treatment for this process is surgical removal of the involved skin and closure of the resulting wound with a flap of adjacent normal skin. However, this aggressive surgery is not always the best near term option because of insurance, financial, work or personal reasons. For early stages of the disease temporizing the situation with topical treatments is appropriate and can provide significant relief.
The Hurley stages of the disease are as follows:
- Solitary or multiple isolated abscess formation without scarring or sinus tracts. (A few minor sites with rare inflammation; may be mistaken for acne.)
- Recurrent abscesses, single or multiple widely separated lesions, with sinus tract formation. (Frequent inflammation restrict movement and may require minor surgery such as incision and drainage.)
- Diffuse or broad involvement across a regional area with multiple interconnected sinus tracts and abscesses. (Inflammation of sites to the size of golf balls, or sometimes baseballs; scarring develops, including subcutaneous tracts of infection. Obviously, patients at this stage may be unable to function.) Brautmodengeschäft Berlin
We now know that there is an inflammatory process present in hidradenitis before there is any sign of infection such as an abscess and I call that pre-stage I. In that stage the skin is intact with redness, tenderness, warmth and burning pains just before an abscess appears. In this early stage there is no drainage and a raised swelling may form a nodule which is very different from an abscess. Some doctors prefer antibiotics and injections of corticosteroids into the affected areas to treat early Stage 1 disease. Others give larger doses of steroids by mouth or testosterone antagonists. Stage III is not amenable to these temporizing measures because of the degree and depth of skin damage but these measures can delay disease progression when employed early in stage I.
Staging of the disease and its appropriate treatment is complicated by a tendency of the disease to go through quiescent and active phases. The person afflicted with HS applies a medication, swallows a pill or changes their diet in some way at a time when the process is about to go quiescent and then mistakenly attributes the quiescence to the medication, pill etc. The treatments described here have been vigorously studied by numerous groups on a variety of wounds including HS. They are employed at assisted living facilities and nursing homes across the country each day