Hidradenitis suppurativa (HS) is a chronic, inflammatory skin condition that causes painful boil-like lumps to form in areas where skin rubs together, such as the armpits, groin, between the buttocks, and under the breasts. For a definite diagnosis of HS, a dermatologist looks for three key criteria:
Criterion 1: Typical HS lesions
The first and most important criterion is the presence of typical HS lesions. These lesions include:
- Painful, red bumps or pimples
- Nodules or hard lumps under the skin
- Abscesses filled with pus
- Open wounds draining fluid or pus
- Scarring and tunnels under the skin from old lesions
At least two typical lesions must be present in characteristic HS locations for a diagnosis. One lesion alone is not enough. The lesions are often swollen, tender, and warm to the touch. They can be sporadic or reoccur in flares.
Criterion 2: Location in HS-prone areas
The second diagnostic criterion is that the typical lesions must occur in areas of the body prone to HS. The most common locations include:
- Armpits (axillae)
- Groin and genitals
- Buttocks
- Under the breasts
- Inner thighs
- Under the stomach
Lesions can occur in other areas as well but are most characteristic in HS predilection sites where skin rubs together. The location helps distinguish HS from similar skin conditions.
Criterion 3: Sinus tract formation
The third diagnostic criterion is the formation of sinus tracts and scarring. A sinus tract refers to a tunnel that forms under the skin when an HS lesion does not fully heal. Instead, it partly closes over but continues to leak fluid and pus underneath the skin. This creates a tract that connects the lesion to the skin surface. Scarring also often occurs.
Sinus tract formation and scarring indicate the chronic nature of HS. They help differentiate it from one-time skin infections. The scars may feel like cords or bands under the skin. They occur as lesions heal over time and can fuse skin together.
Making the diagnosis
Dermatologists diagnose HS by gathering a medical history and performing a physical exam. They look for the three key criteria:
- Typical lesions – At least two lesions in characteristic locations
- Locations – Lesions in HS predilection sites where skin touches
- Chronicity – Sinus tracts and scarring
Sometimes other tests are needed as well, such as a skin biopsy to examine tissue under the microscope. Cultures may be taken to rule out bacterial infection. Blood tests can help exclude associated hormonal disorders.
HS is classified into three stages based on the extent of scarring and sinus tracts:
- Stage 1 (mild) – Single or minor abscess formation without scarring
- Stage 2 (moderate) – Recurrent abscesses with some scarring and possible sinus tracts
- Stage 3 (severe) – Diffuse or near-diffuse involvement with multiple interconnected sinus tracts and abscesses
Early diagnosis leads to better outcomes with HS. Treatment is aimed at managing symptoms and preventing progression to more severe disease.
Key facts about the three diagnostic criteria
In summary, the three necessary criteria for diagnosing hidradenitis suppurativa are:
- At least two typical lesions such as nodules, abscesses, or draining tunnels
- Lesion locations in areas prone to HS like the armpits and groin
- Evidence of chronicity including scars and sinus tract formation
Other supportive factors include a history of recurrent skin infections, family history of HS, smoking, and being overweight. The diagnosis is made clinically based on physical examination. HS can cause significant pain and discomfort. Early recognition allows for better management.
Frequently Asked Questions
What are the first signs of HS?
The earliest signs of HS are typically painful bumps, pimples, or boils in areas where skin rubs together like the armpits, groin, and under the breasts. One of the first lesions may resemble a pimple or infected hair follicle. The lesions tend to be red, swollen, and tender.
How do doctors test for HS?
There are no definitive laboratory or imaging tests to diagnose HS. The diagnosis is made clinically by a physician visually inspecting the skin lesions. Sometimes a skin biopsy or culture is done to rule out other disorders. Blood tests may also be ordered to check for associated hormonal imbalances.
Can HS go away and come back?
HS tends to be a chronic, relapsing disease. Many patients experience flares where symptoms get worse for a period of time and then improve or go into remission. Triggers like hormonal changes, stress, and smoking can cause flares. Proper treatment can help lengthen the remission periods.
Is HS a form of acne?
HS was previously called acne inversa, implying it was a form of severe acne. However, it is now recognized as a distinct disorder different than acne. Acne involves oil glands and hair follicles becoming clogged with oil and bacteria. HS involves deeper inflammation of the hair follicles and sebaceous glands.
Can HS scars be removed?
Wide excision surgery may be done to remove severe scarring from HS lesions. Other options include laser therapy, punch excision, and fillers to make the scars less noticeable. Preventing new lesions is key to avoid further scarring.
The Impact of HS
HS can have a significant impact on a person’s quality of life. Here is an overview of some of the main effects of this condition:
Pain
The lesions of HS are often described as being extremely painful. The boils and abscesses can be tender to the touch. Moving and physical activities can become difficult due to discomfort. Pain may disrupt sleep and daily activities.
Difficulty Moving
When HS occurs in areas like the armpits, groin, and buttocks, it can hamper mobility. The pain and scarring make it difficult to move the affected areas of the body freely. Walking, exercising, and lifting the arms may be impaired.
Odor
Draining wounds and open sores can produce an unpleasant odor. Some people with HS report feelings of self-consciousness. The smell may cause social anxiety and isolation.
Depression
Due to the visibility of lesions in intimate areas and the foul odor they can produce, HS carries a stigma. Many patients report feelings of depression, isolation, and low self-esteem. Quality of life is significantly impacted.
Work/School Absences
The pain and immobility caused by HS flares may require absence from work or school. It also reduces productivity. Young patients may miss out socially due to hiding lesions under clothing.
Intimacy Issues
HS can negatively affect intimate relationships and sex lives due to insecurity, scarring, discomfort, and difficulty moving. Partners may need education about the condition.
Clothing Restrictions
To avoid irritation, many patients limit their wardrobe. Tight clothing or synthetic fabrics can trigger HS flares. Individuals may wear suspenders instead of belts, skirts instead of pants, sleeveless tops, etc.
In summary, HS can be physically and emotionally debilitating. Treatment focuses on managing symptoms and improving quality of life. A multidisciplinary approach including surgery, medications, and lifestyle changes is optimal.
Treatment Options for HS
There are several treatment strategies available for managing hidradenitis suppurativa. The goals are to reduce lesions and pain, prevent new lesions from forming, and minimize scarring. Here are some of the main medical, surgical, and lifestyle treatment options:
Medications
- Antibiotics – Help reduce bacteria on the skin and decrease inflammation and new lesions. Oral antibiotics like tetracyclines, combination sulfonamide, and rifampin are commonly used.
- Anti-inflammatories – Help reduce swelling, tenderness, and pain. Options include non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen.
- Hormonal therapies – Block androgens and other hormones that may exacerbate HS. Birth control pills and spironolactone can help some patients.
- Biologic drugs – Target specific parts of the immune system. Adalimumab (Humira) is the first FDA-approved biologic for HS.
Surgery
- Drainage – Lancing and draining large, painful abscesses helps provide immediate symptom relief.
- Excision – Wide, deep surgical removal of affected tissue helps reduce lesions and prevents recurrence in severe areas.
- Laser therapy – Lasers help diminish scar tissue and encourages new collagen growth to improve appearance.
Lifestyle Changes
- Weight loss – Being overweight or obese increases HS risk. Losing weight relieves friction on skin.
- Smoking cessation – Smoking worsens HS severity. Quitting dramatically helps improve the condition.
- Avoiding friction – Wearing loose, breathable clothing and minimizing rubbing can prevent lesions.
- Warm compresses – Applying warm compresses helps soothe pain and discomfort from flares.
Treatment plans are tailored to each patient based on their symptoms, disease severity, and impacted body areas. A combination approach is often needed to provide adequate relief.
Conclusion
In summary, there are three key diagnostic criteria for hidradenitis suppurativa:
- Typical lesions present – painful nodules, abscesses, etc. in characteristic locations
- Location of lesions in areas prone to HS such as the armpits and groin
- Evidence of chronicity – sinus tracts and scarring
At least two lesions must be present for a diagnosis. HS is a chronic, relapsing skin condition that can significantly impact quality of life. Treatment aims to control symptoms and prevent progression. A multimodal approach utilizing medications, surgery, and lifestyle changes often provides the best outcomes.