Overview and Diagnosis of Hidradenitis Suppurativa (HS)

Andrew Baker, MBA, PA-C: Hidradenitis suppurativa, which I’m going to refer to as HS, is an inflammatory disorder that is characterized by chronic deep-seated nodules, abscesses, fistulas, sinus tracts, and scars in the axilla, inguinal region, inframammary folds, and the perianal area. HS can be accompanied by a lot of pain and embarrassment and can significantly decrease the overall quality of someone’s life.

The pathogenesis of HS is multifactorial, with genetic, environmental, and immunological factors included in both the onset and the maintenance of the condition. More specifically, genetics—we believe that up to about 42% of patients with HS do report a family history of the condition. Also, there are environmental factors such as mechanical stress, metabolic syndrome, obesity, diabetes, diet, smoking, the skin microbiome, and hormonal factors all involved, as well as in the development and the maintenance of HS. And it’s because of the effects of HS on the overall well-being of patients that they have pain, self-esteem problems, sleep disturbances, sexual dysfunction, that clinicians should be aware of the possible development of depression and/or suicidal thoughts in these patients. And then lastly, immunological, this cascade does start with the follicular occlusion that happens. This results from hyperkeratosis of the follicular epithelium. This accumulates cellular debris, and the formation of a keratin plug happens at that time. And the second event is in the rupture of the dilated follicle, which then disperses the keratin fibers, bacteria, and other pathogens, and associated damage with the dermis as well. The follicular rupture then triggers an acute and severe immunological response. This definitely is the main driver of the cytokine, chronic inflammation, and sinus tract formation.

There are many comorbidities with HS, but specifically obesity, metabolic syndrome, inflammatory bowel disease, depression, PCOS [polycystic ovarian syndrome], and tobacco dependence are common with most patients who have HS.

Everyone presents differently, but nothing replaces a thorough history and physical to diagnose HS. There is no specific diagnostic test available to us at this time to diagnose HS. So it’s really just getting to know your patients, developing a rapport with them, and doing a thorough physical exam to find certain areas that are consistent with HS. And as far as staging HS, typically speaking, we use what’s called a Hurley staging. And Hurley staging is divided into stage I, stage II, and stage III. So stage I is a single abscess or multiple isolated abscesses without scar or sinus tract formation. Stage II is recurrent abscesses with either single or multiple scars and/or sinus tract, with widely separated lesions. And then stage III is multiple lesions with extensive scarring and sinus tract formation involving an entire region that is all interconnected.

Why is early treatment important? It is imperative because once these patients have had sinus tract formation, scarring, or surgical intervention, it is so hard to get them to a better baseline. So it’s really important to begin earlier rather than later so it can increase their overall quality of life prior to having some of those irreversible procedures and scarring with sinus tracts.

Transcript Edited for Clarity