Hidradenitis Suppurativa vs. Acne: How to Differentiate and Treat Chronic Inflammation

Diet and Nutrition, General Health
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What is Hidradenitis?

Hidradenitis suppurativa (HS) is a chronic inflammatory disease that affects apocrine glands, which are located in specific areas of the body. These glands secrete a special fluid and are found only in certain regions such as the armpits, groin, around the anus, genitals, buttocks, and under the breasts.

Due to skin folds in these areas, apocrine glands often lack oxygen, leading to blocked secretions and encouraging the growth of pathogenic anaerobic bacteria. If the apocrine glands become clogged and inflamed, this can result in painful nodules and abscesses, which may merge and form tunnels under the skin.

What Are Apocrine Glands?

Apocrine glands are special glands in your body that secrete fluid in response to stress or emotional states. This fluid is different from regular sweat. Apocrine glands produce a thicker fluid that is odorless at first but can develop a strong odor when bacteria interact with it.

Apocrine glands respond to stress, emotions, and hormonal changes. They open into hair follicles, and when they become inflamed and rupture, the fluid released causes inflammation in surrounding tissues, which can lead to the issues mentioned above.

Why Is It Important to Know About HS?

HS can emerge during hormonal changes such as adolescence and puberty. This is a critical time when personal hygiene becomes more independent but still needs close attention. Awareness of HS is essential because the affected areas are often intimate, and teenagers may be embarrassed to seek help from parents or professionals. As a result, the issue often goes unnoticed, leading to disease progression and a significant decrease in quality of life.

The lesions caused by HS are extremely painful and may be accompanied by pus discharge. Even after flare-ups subside, the disease lingers, leaving deep scars and tunnels that can refill with pus. Over time, the condition may worsen significantly, impacting both physical and emotional well-being, especially during hormonal fluctuations. That’s why it’s important to be aware of this condition and know that there are treatments that can greatly improve quality of life.

How to Distinguish HS From Acne and Other Skin Conditions?

HS can be difficult to distinguish from other skin conditions because its symptoms may resemble acne or boils. Here are some key differences:

  • Location: HS occurs in areas with apocrine glands (armpits, groin, around the anus and genitals), while acne is more common on the face, back, and chest, and boils can appear anywhere. HS may also develop in less common areas such as near the ear or around the navel. A few people have developed HS on the face, neck, or back, but this is rare.
  • Chronic nature: HS is chronic and often recurs, requiring long-term treatment, unlike temporary acne.
  • Sinuses and tunnels: HS is characterized by the formation of sinuses and tunnels under the skin, which are not typical for acne or boils.
  • Response to treatment: Traditional acne treatments or antiseptics are ineffective for HS, which requires specific interventions.
  • Hormones and immunity: HS is linked to hormonal changes and autoimmune reactions, unlike acne and boils, which are more related to bacterial infections and skincare.

Key Signs and Symptoms of HS

Symptoms of HS vary depending on the stage of the disease:

  1. Appearance of a painful lump
    A small lump appears that may be painful when pressed. It may resemble a typical pimple but causes significant discomfort and pain.
  2. Redness and inflammation
    Soon, redness and inflammation develop around the lump. The skin may become hot to the touch and painful, indicating active inflammation.
  3. Pus formation
    As inflammation progresses, the lump may fill with pus, which may be thick, cloudy, or yellowish. At this stage, it may resemble acne, leading to a desire to squeeze it. However, squeezing worsens the situation—spreading the infection deeper.
  4. Formation of tunnels
    If inflammation continues, pus-filled lesions may connect under the skin, forming painful and itchy tunnels or sinuses. These tunnels are often hidden, making diagnosis and treatment more difficult.
  5. Scarring and skin thickening
    After the inflammation subsides, scars may remain. These can be thickened and alter skin texture. Over time, they often become more visible, affecting both appearance and skin function.

If you notice these symptoms, it’s important to see a doctor. Early treatment can prevent serious complications and improve quality of life.

What Are the Risk Factors and Predisposing Conditions?

HS is a complex disease with not fully understood causes. Several factors may increase the likelihood of developing HS:

  1. Genetic predisposition
    Genetics play an important role in the development of HS. If close relatives have or had HS, the risk of developing it is higher.
  2. Hormonal factors
    Hormonal changes, especially during adolescence and the menstrual cycle, can contribute to HS onset. HS often develops during hormonal fluctuations (puberty, pregnancy, menopause), which increase inflammation and block apocrine glands. The condition is more common in women.
  3. Excess weight and obesity
    People with excess weight have an increased risk of developing HS. This may be due to more sweating and friction in skin folds.
  4. Smoking
    Cigarette smoking is associated with a higher risk of HS. Chemicals in tobacco smoke can worsen skin condition and promote inflammation.
  5. Metabolic disorders
    Some metabolic conditions, such as diabetes or polycystic ovary syndrome, can increase HS risk.
  6. Chronic autoimmune diseases
    People with chronic autoimmune diseases such as Crohn’s disease or arthritis may be more prone to HS.
  7. Infections and skin damage
    Recurrent infections, trauma, and skin irritation can contribute to HS by causing inflammation and blocking apocrine glands. HS is often accompanied by anaerobic bacteria such as Cutibacterium acnes and Peptostreptococcus, which contribute to abscess and sinus formation.

How Is HS Diagnosed?

Diagnosis is clinical, meaning it is based on the patient’s history and visual examination. It is essential to find a doctor who is familiar with this condition. A dermatologist will always recognize HS. The classification of HS stages was proposed by Hurley in 1989. This system divides the disease into three stages based on the severity of symptoms and skin changes:

  1. Stage I (mild)
    Single or several inflamed nodules without abscess or scarring. Inflammation is localized, and skin structure remains intact.
  2. Stage II (moderate)
    Recurrent nodules and abscesses that may connect via subcutaneous tracts (sinuses), leading to scarring. Lesions are more widespread but do not fully merge.
  3. Stage III (severe)
    Multiple interconnected nodules, abscesses, and fistulas forming large affected areas with numerous scars and sinuses. Inflammation is extensive, and the skin is significantly damaged.

Content warning: This article contains images and descriptions of skin diseases that may be unpleasant to some readers. Viewer discretion advised. Stages of Hidradenitis Suppurativa

Modern Treatments for HS

  1. Lifestyle changes and diet
    • Weight loss: losing 5–10% of body weight (if overweight) may reduce symptoms.
    • Diet: a low-sugar, Mediterranean-style diet is recommended to reduce inflammation. Avoiding dairy, gluten-containing foods, and identifying food intolerances may also help.
  2. Conservative treatment
    • Topical antiseptics and antibiotics: to control infection and reduce inflammation.
    • NSAIDs: to relieve pain and inflammation.
  3. Medication therapy
    • Systemic antibiotics: for severe infections.
    • Corticosteroids: to control inflammation.
    • Immunosuppressants and biologics: used in severe forms of HS.
  4. Supplements
    • Adding vitamins and minerals such as vitamin D and zinc may support the immune system and improve skin health.
  5. Surgical treatment
    • Abscess drainage: to remove pus.
    • Surgical excision: for severe and chronic HS.
  6. Innovative methods
    • Laser therapy: to remove inflamed tissue.
  7. Liquid nitrogen insufflation
    • Cryotherapy using liquid nitrogen can be used to treat HS tunnels. The method involves injecting nitrogen into the tunnel with a needle.

How Lifestyle Changes Can Help

  • Regular cleansing: Keeping commonly affected areas clean can help prevent infections and flare-ups. However, avoid aggressive actions like squeezing, which can worsen the condition.
  • Avoiding triggers: Identifying and avoiding factors that contribute to flare-ups (such as overheating, friction, and stress) can help manage symptoms.
  • Lymphatic system: Regular physical activity can improve lymphatic system function.
  • Smoking: Quitting smoking can improve overall health and reduce inflammation.
  • Other aggravating factors: Obesity, tight clothing, excessive deodorant use, and shaving increase HS risk.
  • Natural fabrics: Wear breathable natural fabrics such as cotton to reduce friction and sweating in problem areas.

Risk Groups

  1. People with metabolic disorders Obesity and high blood sugar levels.
  2. Smokers Smoking exacerbates inflammation.
  3. Women The condition is more common in women, especially between ages 20–40.
  4. People with autoimmune diseases HS often coexists with other inflammatory conditions, such as Crohn’s disease.
  5. African Americans and people of mixed race Studies show a higher risk of HS in African Americans.

HS Complications May Include

  1. Infectious complications The spread of infection from inflamed nodules and abscesses may lead to cellulitis, chronic fistulas, and sepsis—a life-threatening condition in which the infection enters the bloodstream and causes systemic inflammation.
  2. Physical complications Formation of scars, sinuses, and tunnels under the skin can lead to restricted movement in affected areas and chronic pain.
  3. Increased risk of other diseases People with HS are at greater risk of cardiovascular disease and squamous cell carcinoma of the skin.
  4. Psychological complications Chronic pain, scarring, and restricted mobility can lead to depression, anxiety disorders, and reduced quality of life.

Important to Know

  • HS is not contagious: It is not transmitted through contact or sexually.
  • Timely treatment is required: Without treatment, the disease may progress, causing abscesses and scarring that can lead to complications, including disability.
  • Diagnostic difficulty: Many patients live with HS for an average of five years before being diagnosed due to its similarity to other skin conditions like acne and boils.

Conclusion

Hidradenitis suppurativa (HS) is a chronic inflammatory condition that requires a comprehensive treatment approach. Modern methods include lifestyle changes, medication, and innovative procedures. Effective symptom management is possible with early medical intervention and adherence to recommendations such as quitting smoking, maintaining a healthy weight, and avoiding triggers. Seeing a dermatologist can speed up diagnosis and improve treatment outcomes. It’s important to remember that HS is not contagious, and minimizing complications and improving quality of life requires an individualized approach.