Hidradenitis suppurativa is a chronic inflammatory disease of hair follicles in skin folds such as the armpits, groin and under the breasts. It causes painful lumps and abscesses that keep coming back, can form tunnels and scars, and is linked to smoking and obesity.
Key symptoms
- Painful deep lumps that come back in the same areas
- Lumps that open and drain bad-smelling pus or blood
- Armpits, groin, buttocks and under the breasts most often
- Flares with periods, friction or heat
- Strong impact on mood, work and intimacy
What you find on exam
- Tender nodules and abscesses in skin folds
- Draining tunnels (sinus tracts) and rope-like scars
- Paired blackheads (double-ended comedones)
- Hurley stage: I nodules only, II tunnels with normal skin between, III connected tunnels across an area
- Look for linked problems: acne, obesity, inflammatory bowel disease, arthritis
Tests
- Diagnosis is clinical, based on lesion type, site and recurrence
- Bacterial culture only if a lesion looks truly infected
- Screen glucose, lipids and blood pressure for metabolic risk
- Depression screening with the PHQ-9
Treatment basics
- Mild disease: topical clindamycin and antiseptic washes such as chlorhexidine
- Injection of triamcinolone into a single painful nodule
- Moderate disease: oral doxycycline, or clindamycin with rifampin
- Severe disease: adalimumab or secukinumab, and surgery to remove tunnels
- Stop smoking, lose weight, wear loose clothing; incision and drainage gives only short relief
Red flags
- Fever, spreading redness or signs of sepsis
- Large, very painful abscess with fluctuance
- Ulcer that does not heal in old scars (rare squamous cell carcinoma)
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.