Hidradenitis suppurativa

Last updated: September 7, 2023

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Summarytoggle arrow icon

Hidradenitis suppurativa is a chronic inflammatory skin condition characterized by recurrent follicular inflammation, typically in the intertriginous areas. Manifestations include painful skin lesions (nodules and abscesses), draining sinus tracts, and scarring; the severity of symptoms varies. The disease typically affects young adults. The exact etiology is unknown but likely multifactorial and thought to involve blockage of hair follicles. Diagnosis is clinical and treatment includes wound care, pain management, and pharmacotherapy. Psychological support may be required for mental health conditions that can be associated with hidradenitis suppurativa. Surgical interventions may be needed for severe and/or recurrent disease. Complications include disfigurement resulting from excessive scarring, bacterial superinfection, and, in affected areas, cutaneous squamous cell carcinoma.

Epidemiologytoggle arrow icon

  • Prevalence: 0.1–2%
  • Average age of onset: 18–39 years
  • More common in:
    • Women
    • Individuals of African descent
    • Individuals with a family history of hidradenitis suppurativa

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

The exact etiology of hidradenitis suppurativa is unknown, but the following factors may contribute to the development and/or severity of the disease: [2][3][4]

Pathophysiologytoggle arrow icon

Blockage of hair follicle → dilation and rupture → spilling of follicular contents into dermis inflammatory response → abscess formation and destruction of the pilosebaceous unit [2][3][4]

Clinical featurestoggle arrow icon

  • Localized in intertriginous areas containing apocrine glands (most commonly the axillae, groin, inner thigh, perineal and perianal areas)
  • The first lesion is usually a solitary painful inflammatory nodule that progresses to an abscess that may open or regress spontaneously.
  • Sinus tracts may form between multiple recurrent nodules and drain foul-smelling, seropurulent discharge.
  • Development of open ; and closed comedones
  • Scarring ranges from small, individual acneiform scars to thick scarred plaques that affect larger areas of skin.

Diagnosticstoggle arrow icon

Diagnosis is clinical, based on both of the following. [2][3][4]

Differential diagnosestoggle arrow icon

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

General principles [2][3][4]

Hidradenitis suppurativa is a chronic condition with no cure and requires chronic disease management.

  • Provide supportive care, including pain management.
  • Screen for and manage hidradenitis suppurativa-associated comorbidities.
  • Initiate first-line pharmacological therapies, which may include:
    • Topical or intralesional therapies
    • Systemic therapies (e.g., oral antibiotics, hormonal therapy)
  • Refer patients with moderate, severe, or refractory disease to dermatology for management. [4]

Supportive care [2][3][7]

Hidradenitis suppurativa-associated comorbidities [2][3][4]

Screen for and manage the following conditions that commonly co-occur with hidradenitis suppurativa:

Recommend weight reduction to patients with obesity, as it may improve the severity of disease. [2]

Pain, malodorous drainage, and scarring often negatively impact the patient's quality of life. [3][4]

Pharmacological therapy [2][3][7]

Treatment may include different combinations of the following, depending on the severity of disease:

Localized therapies

Systemic therapies

Procedural interventions [2][3][4]

For lesions refractory to pharmacological therapy, any of the following may be performed:

Acute lesions

Chronic lesions

  • Deroofing of recurrent nodules, abscesses, and sinus tracts [2][8]
  • Wide local excision with skin grafts for extensive, chronic disease and scarring
  • Laser therapy (e.g., Nd:YAG laser, CO2 laser)

Complicationstoggle arrow icon

We list the most important complications. The selection is not exhaustive.

Prognosistoggle arrow icon

  • Chronic with a high rate of recurrence [4][10]
  • Decreases quality of life [10]

Referencestoggle arrow icon

  1. Alikhan A, Sayed C, Alavi A, et al. North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations. J Am Acad Dermatol. 2019; 81 (1): p.76-90.doi: 10.1016/j.jaad.2019.02.067 . | Open in Read by QxMD
  2. Garg A, Naik HB, Kirby JS. A Practical Guide for Primary Care Providers on Timely Diagnosis and Comprehensive Care Strategies for Hidradenitis Suppurativa. Am J Med. 2023; 136 (1): p.42-53.doi: 10.1016/j.amjmed.2022.09.025 . | Open in Read by QxMD
  3. Wipperman J, Bragg DA, Litzner B. Hidradenitis Suppurativa: Rapid Evidence Review. Am Fam Physician. 2019; 100 (9): p.562-569.
  4. Rosi E, Guerra P, Silvi G, et al. Consistency of Bacterial Triggers in the Pathogenesis of Hidradenitis Suppurativa. Vaccines (Basel). 2023; 11 (1): p.179.doi: 10.3390/vaccines11010179 . | Open in Read by QxMD
  5. Johnston LA, Alhusayen R, Bourcier M, et al. Practical Guidelines for Managing Patients With Hidradenitis Suppurativa: An Update. J Cutan Med Surg. 2022; 26 (2_suppl): p.2S-24S.doi: 10.1177/12034754221116115 . | Open in Read by QxMD
  6. Alikhan A, Sayed C, Alavi A, et al. North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations. J Am Acad Dermatol. 2019; 81 (1): p.91-101.doi: 10.1016/j.jaad.2019.02.068 . | Open in Read by QxMD
  7. van der Zee HH, Prens EP, Boer J. Deroofing: A tissue-saving surgical technique for the treatment of mild to moderate hidradenitis suppurativa lesions. J Am Acad Dermatol. 2010; 63 (3): p.475-480.doi: 10.1016/j.jaad.2009.12.018 . | Open in Read by QxMD
  8. Moosbrugger EA, Mutasim DF. Hidradenitis suppurativa complicated by severe lymphedema and lymphangiectasias. J Am Acad Dermatol. 2011; 64 (6): p.1223-1224.doi: 10.1016/j.jaad.2009.10.045 . | Open in Read by QxMD
  9. $Contributor Disclosures - Hidradenitis suppurativa. None of the individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy.
  10. Micheletti, MD RG. Natural History, Presentation, and Diagnosis of Hidradenitis Suppurativa. Semin Cutan Med Surg. 2014; 33 (3S): p.S51-S53.doi: 10.12788/j.sder.0092 . | Open in Read by QxMD

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