Understanding hidradenitis suppurativa to achieve earlier diagnosis and better treatment
Introduction
Painful nodules that keep coming back under the arms, in the groin or under the breasts, abscesses that flare up, drain and then recur, sometimes for years on end: hidradenitis suppurativa (also known as Verneuil’s disease or acne inversa) is a chronic inflammatory skin condition that is both common and widely misunderstood.
On average, patients wait 6 to 10 years before receiving a correct diagnosis. During that time, the disease progresses, scarring accumulates and quality of life deteriorates. A better understanding of hidradenitis suppurativa is key to enabling earlier and more effective management.
What is hidradenitis suppurativa?
Hidradenitis suppurativa is a chronic autoinflammatory disease affecting the hair follicles in areas rich in apocrine glands. It presents with nodules, abscesses, tunnels (sinuses) and scars in the skin folds.
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An autoinflammatory disease differs from an autoimmune disease: in autoimmune conditions, the immune system produces antibodies against its own tissues. In HS, it is the innate immune system that overreacts without specific antibodies, triggering chronic local inflammation. In 2024, HS was officially classified among the autoinflammatory keratinization diseases.
The condition affects approximately 1% of the world’s population, with a clear female predominance. It typically begins after puberty, between the ages of 20 and 30, and can persist throughout life.
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Hair follicles are the tiny structures in the skin from which hairs grow. In HS, these follicles become blocked, dilate and then rupture, triggering an intense inflammatory response deep within the skin.
How does the disease develop?
The process begins with follicular occlusion: the hair follicle canal becomes blocked, leading to an accumulation of keratin and sebum. The follicle dilates, then ruptures, releasing its contents into the dermis. This rupture triggers an intense inflammatory response, with an influx of immune cells and the release of pro-inflammatory cytokines such as TNF-α and interleukins IL-1β and IL-17.
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Cytokines are signalling proteins produced by immune cells. TNF-α (Tumour Necrosis Factor alpha) and IL-17 are particularly involved in HS: blocking them with biological medications (biologic therapies) is now one of the most effective treatments for moderate to severe forms of the disease.
Without treatment, this repeated inflammation leads to the formation of subcutaneous tunnels (sinuses), fibrotic scarring and progressive spread of the lesions. This is why early diagnosis and management are decisive.
Factors that aggravate hidradenitis suppurativa
HS is a multifactorial disease. Several elements can trigger or worsen flare-ups:
Smoking is the best-documented aggravating factor. Smokers present with more severe forms and respond less well to treatment. Stopping smoking is consistently recommended.
Overweight and obesity increase friction in skin folds and promote systemic inflammation. Even modest weight loss can significantly improve symptoms.
Repeated friction from tight clothing or repetitive movement irritates the follicles and encourages flare-ups.
Genetics also plays a role: approximately one third of patients have a family history of HS, suggesting a hereditary predisposition.
Hormonal fluctuations, particularly the menstrual cycle, can trigger flare-ups in some women.
Stages of the disease
HS is classified according to the Hurley staging system, which helps assess severity and guide treatment:
Hurley staging:
• Stage I: isolated nodules and abscesses, no sinuses or significant scarring
• Stage II: recurrent lesions with early sinuses and scarring, moderate involvement
• Stage III: extensive involvement with multiple sinuses, significant scarring and severe impact on quality of life
Available treatments
The management of HS is stepped according to severity. There is no universal treatment, and personalisation is essential.
Topical treatments are the first line in mild forms: antiseptics, topical antibiotics (clindamycin), topical retinoids. They aim to reduce bacterial colonisation and local inflammation.
Oral antibiotics, notably the combination of tetracycline and rifampicin, are used in moderate forms for their anti-inflammatory effects. Their use is time-limited to avoid resistance.
Biologic therapies represent the major therapeutic advance of the last decade. Three medications are now available for moderate to severe forms:
- Adalimumab (anti-TNF-α) — the first biologic approved for HS
- Secukinumab (anti-IL-17A) — approved in Europe in 2023
- Bimekizumab (anti-IL-17A/F) — approved in late 2024, with very promising results
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A biologic medication (or biotherapy) is manufactured from living cells and precisely targets a specific inflammatory molecule. Unlike conventional anti-inflammatory drugs, which act broadly, biologics block a precise link in the inflammatory chain, reducing systemic side effects.
Surgery remains indicated in severe forms or where scarring is extensive. Wide excision of the affected areas is the most effective technique for preventing local recurrence.
When to consult a dermatologist?
It is recommended to seek medical advice promptly if:
- Painful nodules or abscesses have been recurring in skin folds for more than 6 months
- Lesions affect several areas (armpits, groin, under the breasts, buttocks)
- Tunnels or scarring are beginning to form
- Pain or discomfort is affecting daily life, work or sleep
- Previous treatments (antibiotics, topical care) have been insufficient
An early diagnosis allows appropriate treatment to be put in place before lesions progress to more severe and harder-to-treat stages.
Living well with hidradenitis suppurativa
HS is a chronic condition that can have a significant impact on quality of life, self-esteem and mental health. Several measures can help on a daily basis:
- Gentle hygiene: superfatted or soap-free cleansers, avoiding irritating products
- Loose-fitting clothing: minimising friction in affected areas
- Stopping smoking: the single most impactful measure on disease progression
- Weight management: even modest weight loss can improve symptoms
- Psychological support: do not hesitate to discuss this with your doctor; patient associations exist
Conclusion
Hidradenitis suppurativa is not « just spots ». It is a serious chronic inflammatory disease that deserves rigorous dermatological management. Recent therapeutic advances, particularly the new biologic therapies, now offer real prospects for patients who have been suffering for years. If you recognise yourself in this article, seek help: a diagnosis made early makes a radical difference to the outcome.
Scientific references
1. Vinkel C. et al. — Hidradenitis Suppurativa: Causes, Features, and Current Treatments — Journal of Clinical Medicine, 2023. https://doi.org/10.3390/jcm12062458
2. Kimball A.B. et al. — Bimekizumab in Hidradenitis Suppurativa — The Lancet, 2024. https://doi.org/10.1016/S0140-6736(23)02504-X
3. Jfri A. et al. — Autoinflammatory Keratinization Diseases — JAMA Dermatology, 2023. https://doi.org/10.1001/jamadermatol.2023.0505
4. Prens E., Deckers I. — Pathophysiology of Hidradenitis Suppurativa — Nature Reviews Disease Primers, 2021. https://doi.org/10.1038/s41572-021-00298-3
5. Ingram J.R. et al. — British Association of Dermatologists Guidelines for HS — British Journal of Dermatology, 2023. https://doi.org/10.1093/bjd/ljad465
Article written and published by DermInfos