Hidradenitis Suppurativa: Boils & Cysts

Let's talk about hidradenitis suppurativa (HS)... boils, cysts can be frusturating and painful!

Hidradenitis suppurativa is a chronic inflammatory skin condition that has been increasingly recognized by not only the dermatologic community, but the community at large as a growing concern.

The psychosocial impact and prejudice created overtime among those individuals with hidradenitis suppurativa has empowered dermatologists to advocate and understand the disease process.

What does it look like? Well, it often appears as painful bumps, nodules and accesses on the surface of the skin.

Why do they happen? There are 2 factors that cause HS- Genetics & Environmental Factors. Think about it as everyone has a special lock which they are born with. One day there is a special 'key' that we are in contact that opens up this lock triggering a breakout.

HS occurs because of blockage of hair follicle openings which leads to skin inflammation and formation of cysts. The blockage of the hair follicles also allows the accumulation of bacteria that normally live on the skin to over-produce which is what causes pus-filled abscesses and draining cysts. The exact underlying cause for the blockage of hair follicles is unknown.

Where do they cysts typically occur? Typically these boils and cysts occur in the groin, armpits (axillae), underneath the breasts and buttock. However, they can also occur on the abdomen and where there is excess skin or when skin is in direct contact with skin (friction is a common trigger--see below!).

Psychosocial impact: Many of my patients impacted with groin and breast lesions often voice their anxiety with participating in sexual practices as a result of embarrassment and pain, drainage and discomfort during sexual practices when lesions are active.

Treatment of HS is frequently dependent on the severity (the clinical stage of disease). Mild cases of HS where no scarring of the skin is present may be managed by a combination of at-home remedies and topical and/or oral antibiotics.

Prevention is key! Counseling on warm compresses, antibacterial soaps, antiseptics, weight loss, smoking cessation, wearing loose-fitting clothing and anti-inflammatory over-the-counter medications is at times just as important as prescription treatment. Prior to scarring, laser hair treatment may be helpful in the removal of the hair follicles as not only as treatment, but also a preventative measure.

What if I have a lot of scarring?

In more severe cases where scarring may be present, draining and pain is poorly controlled with topical and/or oral antibiotics, oral or injectable immunosuppressive medication may be helpful.

Biologic medications-Initially prescribed fro psoriasis, psoriatic arthritis and chron’s disease, certain biologic medications (i.e. a class of medications that are either available as injections or infusions that suppress a component of the immune system) are increasingly used in the treatment of HS. In 2015, Humira was approved for the treatment of moderate to severe HS.

Oral retinoid treatment (i.e. isotretinoin, also known as Accutane) may be used in the treatment of HS, especially in those with a history of acne. Isotretinoin functions to reduce the size of the sebaceous gland, the oil producing gland.

Injectable steroid- Dermatologists may inject steroid into painful and/or persistent cysts and boils to decrease inflammation and scarring.

Oral antibiotic treatment- Combination of oral antibiotics and topical antibiotics are often used in the treatment of early, mild-to-moderate HS.

Hormonal treatment- In females with groin and breast lesions flaring around their menstrual period, oral spironolactone may be a helpful treatment. Sprionolactone has been used for many years for the treatment of hormonal acne (acne distributed in the lower cheeks, jawline and flares around the menstrual period).

New, alternative treatment(s):

When inflammation is poorly controlled, your dermatologist may consider adding on oral zinc gluconate. It has been shown in studies to help reduce inflammation within 3-6 months in HS patients. I have found that it’s long-term use has been limited by abdominal pain and nausea, the most common side effects.

Oral Tumeric- Anti-inflammatory properties has been shown in small studies to be helpful in decreasing skin inflammation. Additional studies are needed to evaluate effectiveness in HS treatment.

Surgical treatment- When scarring is severe and extensive, surgical removal of the lesions and skin grafting of the areas may be helpful. It is important that prior to surgery, inflammation and breakouts are minimized to help ensure the best surgical outcome and avoid recurrence after surgery.

Remember: Treatment of HS is not a one size fits all approach and that at times, it may feel like a trial and error; however, with a growing number of treatments there is hope for better control of their disease. HS does not only impact the skin, but also has bearing on their personal and professional life.

Take a more confident, empowered and active role in their skin health by seeking outside resources and advice through the Hidradenitis Suppurativa Awareness Organization, No BS about HS among other online resources (see link below)!