Miss G was a 22-year-old, slightly overweight woman whose medical records were sparse and unremarkable. I had not seen her for some time, but remembered her as being smartly dressed and cheerful.
Now she looked tired, dishevelled and close to tears. 'I'm sorry, doctor,' she managed at last, 'I'm so depressed.' I encouraged her to tell me what was troubling her.
'It's me,' she said, 'I'm disgusting. And my boyfriend can't stand it any longer, he's gone and I don't blame him.' Puzzled, I asked her why she thought she was disgusting.
'Because of this,' she said, pulling up her sweater and showing me her armpits. 'And it's under my breasts, and down there, too,' she said, putting a hand on her groin. I summoned the nurse and examined the relevant parts of Miss G's anatomy.
In each of the sites she had indicated, there was a mixture of small boil-like swellings, some of which were inflamed and oozing pus, interspersed with comedones and evidence of scarring.
There was also an unpleasant and characteristic smell, which Miss G pointed out before I faced the difficulty of mentioning it.
'I thought it was just a sort of acne,' she said, 'but it's been going on for months. I thought I wasn't clean, but however much I wash and shower, it doesn't make any difference.'
The condition had nothing to do with personal hygiene, I assured her. I explained that I thought she had hidradenitis suppurativa (HS) and that I would refer her to a dermatology consultant.
I also explained that while it was not easy to get rid of HS, a lot could be done to improve the situation.
Miss G left in a much better state of mind, knowing that she had a recognised condition, it was not her fault and help was on the way.
Causes of HS
The cause is uncertain, but HS is a result of the blockage of apocrine sweat glands and hair follicles. Sweat is trapped and the glands swell, rupture and become inflamed or infected.
It occurs most commonly in areas rich in apocrine glands, so the axillae, groin, perineum, perianal and submammary regions are most affected. HS may be related to a problem with the immune system and it is suggested that it may be linked to Crohn's disease. Some recent research has suggested that the main cause is a defect in the follicular support tissue.1
Other factors undoubtedly play a part, including genetic factors, the stimulation of apocrine glands by androgens and their suppression by estrogen, and cigarette smoking. Obesity, polycystic ovaries, hirsutism and acne are also more frequent in women with HS.
Women are affected about three times as often as men, and it is most common in those aged 20-40 years and coincides with the post-pubertal increase in androgen levels.
The condition is usually separated into three stages. Stage one involves solitary or multiple isolated abscesses without scarring. Stage two involves recurrent abscesses with sinus tract formation. Stage three, diffuse involvement, presents with multiple interconnected sinus tracts and abscesses.
Early lesions may heal without treatment, but later recurrent lesions may reach the size of a golf ball, become infected and painful, and discharge pus.
Treatment of HS
Treatment of the condition is often difficult. General measures may help considerably, such as stopping smoking, weight reduction, wearing loose clothing to avoid chafing, and the application of skin antiseptics, acne preparations or hydrogen peroxide to reduce the skin population of potentially troublesome bacteria.
Medical management includes topical antibiotic and benzoyl peroxide preparations, and the use of systemic antibiotics for acute abscesses. For refractory episodes, a prolonged course of antibiotics may be used to reduce colonisation.
Other measures include a trial of the combined oral contraceptive pill for at least a year, with those containing anti-androgenic progesterones being the most effective.
More specialised treatments and surgical measures may also be required in some cases.
I saw Miss G again six months later. She had initially been treated with a prolonged course of systemic antibiotics with topical benzoyl peroxide. This was maintained, along with weight loss and an anti-androgenic combined pill.
She said her life had been transformed. Her HS had been in remission for three months and she had met a new boyfriend. It reminded me that conditions such as this can have consequences far beyond the disease itself.
- Dr Barnard is a former GP from Fareham, Hampshire
1. Danby FW, Jemec GB, Marsch WC et al. Preliminary findings suggest hidradenitis suppurativa may be due to defective follicular support. Br J Dermatol 2013; 168(5): 1034-9.