Hidradenitis Suppurativa (HS) Flare-Up: Causes, Treatment

Hidradenitis Suppurativa (HS) Flare-Up: Causes, Treatment


Hidradenitis suppurativa (HS), also called acne inversa, is a chronic (long-term) inflammatory skin condition characterized by painful skin lesions. The lesions can range from small lumps and pus-filled abscesses to pus-filled tunnels and permanent skin scarring. They often develop in areas where skin touches skin, such as the inner thighs, armpits, and groin (the region between your abdomen and thigh).

People with HS experience periods of new or worsening symptoms or flares followed by periods of remission or relief. HS flare-ups are mostly unpredictable and may last a few hours or days. Some people experience symptoms such as skin itching, fatigue, nausea, or menstrual changes just before a flare-up, but lesions might also occur suddenly on their own.

Understanding HS flare-ups can help you manage them more effectively.

HS is a chronic skin condition that develops due to clogging of hair follicles. The condition has periods of symptom worsening called flares. Flares can last for a few hours or a few days and are followed by periods of remission. They often occur unpredictably and may continue for years if left untreated.

You may experience certain warning signs before a flare-up occurs. These include headache, nausea, fatigue, skin itching, or menstrual changes.

Common symptoms of HS flare-ups include:

  • Small lumps that look like acne or boils
  • Lumps that join together to form painful abscesses that are filled with fluid
  • Abscesses that break open, leading to the fluid spilling out and scar formation
  • Blackhead-like spots that appear in pairs
  • Pus-filled tunnels or sinus tracts that develop due to the formation of abscesses and scars in the same area

A secondary bacterial infection can develop on the skin if HS lesions are left untreated.

The exact cause of HS is still unknown. Research suggests that HS develops due to blockage of hair follicles with keratin. Keratin is a protein that helps to form the tissues of hair, nails, and the outer layer of skin. Clogging results in the build-up of keratin, sweat, and bacteria inside the hair follicle.

Over time, the clogged hair follicle bursts. This activates the immune system activation, which causes inflammation and abscess formation.

HS flare-ups can also occur due to hormonal changes. This might happen during life stages like pregnancy, puberty, and menopause. Such flare-ups are often caused by a decrease in the levels of estrogen and progesterone hormones.

Other factors that may trigger HS flare-ups include:

  • Diet: Your diet may play an essential role in triggering HS flare-ups. Consumption of foods containing dairy, high sugar content, or brewer’s yeast (Saccharomyces cerevisiae) can increase the risk of flare-ups.
  • Smoking: Smoking can increase your risk of frequent HS flare-ups. About 70% of people with HS are smokers.
  • Obesity: People who are obese have a higher chance of getting frequent HS flare-ups. This may be due to increased skin friction and sweat production.
  • Tight-fitted clothing: Tight clothing can rub against the skin and irritate the parts of your skin with HS lesions, thereby worsening symptoms.
  • Weather conditions: Exposure to hot and humid weather conditions can increase sweating and worsen HS symptoms.
  • Stress: Stress can often trigger an HS flare-up, but HS can also cause stress.

There is currently no cure for HS. Treatment approaches focus mainly on improving people’s symptoms and quality of life. Treatment for HS includes lifestyle modifications, self-care tips, medications, and surgery, depending on the severity of the condition. You’ll work with a dermatologist—a medical doctor who specializes in skin, hair, and nails.

Self-Care Tips 

Common self-care tips can prevent skin irritation and prevent HS from worsening. For example:

  • Use antimicrobial wash: Washing your skin with antimicrobial wash can reduce bacteria, which leads to fewer flare-ups. Antimicrobial washes containing benzoyl peroxide or zinc pyrithione are most often preferred to reduce flare-up symptoms.
  • Wash gently: Scrubbing your skin can cause inflammation and worsen HS symptoms.
  • Try warm compresses: Using warm water or a black teabag compress can help reduce HS pain.
  • Use mild deodorant or antiperspirant: Deodorants or antiperspirants containing baking soda, parabens, dyes, fragrances, or alcohol might be too harsh for the skin and lead to HS flare-ups.
  • Minimize sweating: Exposure to hot or warm places can cause sweating, worsening HS.
  • Wax and shave carefully: Waxing or shaving can irritate the skin if not done with caution.

Lifestyle Modifications

Lifestyle modifications that can help to prevent HS flare-ups include:

  • Avoid smoking: Reducing or quitting smoking can help to prevent HS flare-ups.
  • Maintain a healthy weight: Losing weight can help prevent flare-ups, especially for overweight or obese people.
  • Eat a healthy diet: An anti-inflammatory, whole-food diet, such as a plant-based or Mediterranean diet, can prevent HS flare-ups.

Medications

Dermatologists often recommend medications based on the location of the lesions and the severity of your condition. Mild cases can improve with topical medications (applied to the skin), but moderate to severe cases often require oral medications (taken by mouth). 

Common medications to improve HS symptoms and reduce flare-ups include:

  • Topical resorcinol: Topical resorcinol can reduce pain and speed up healing.
  • Topical antibiotics: Topical antibiotics such as Cleocin (clindamycin) can reduce the number of lesions and the risk of infections.
  • Oral antibiotics: Oral antibiotics such as Sumycin (tetracycline) are often recommended in cases of HS that are widespread and difficult to treat.
  • Hormone therapy: Hormone therapy using Androcur (cyproterone acetate) can be useful in suppressing HS flare-ups.
  • Biologics: Biologics can help reduce inflammation and flare-ups in people who do not respond to conventional medications. Currently, only one biologic, Humira (adalimumab), has been approved by the U.S. Food and Drug Administration (FDA) for HS treatment.
  • Diabetes medication: In some cases, the diabetes medication Fortamet (metformin) can help reduce inflammation and manage flare-ups.

Procedures and Surgery

Severe cases of HS may require certain procedures along with medications, such as:

  • Corticosteroid injections: These injections can reduce inflammation and control flare-ups. However, their use must be avoided in case of secondary bacterial infection.
  • Incision and drainage: This procedure involves making a small cut at the center of the abscess and draining the pus. This helps reduce pain and speed healing.
  • Deroofing: During this procedure, the top layer (“roof”) of an abscess or sinus tract is removed. The wound is then kept open to heal, reducing the lesion’s likelihood of reforming. This procedure is often recommended for people who repeatedly experience HS lesions in the same location.
  • Wide excision: This procedure involves removing HS lesions and some healthy tissue around them. Like deroofing, the wound is left open to heal on its own.
  • Laser surgery: In severe cases of HS, laser surgery using CO2 laser or Nd:YAG laser excision can help remove HS lesions. After surgery, your skin may require up to six months to heal.

HS can significantly reduce your quality of life by affecting your emotional wellbeing in addition to causing physical symptoms. You may experience symptoms of anxiety or depression, decreased work performance, or social isolation. Coping strategies include:

  • Get a customized treatment plan that works best for you
  • Avoid being alone and spending time with family and friends
  • Join an HS support group
  • Meet with a mental health provider (e.g,. a therapist)
  • Practice yoga, meditation, or other mindfulness exercises

The symptoms and severity of HS can vary from one person to another. Consider visiting a dermatologist if you:

  • Develop lesions on more than one part of your body
  • Experience flare-ups even with treatment
  • Experience intense pain
  • Have difficulty walking or sitting

HS flare-ups are periods of new or worsening of symptoms. Although flare-ups are often unpredictable, certain factors can trigger them. Triggers include dairy and high-sugar diets, stress, hot and humid weather, tight clothing, and smoking.

Several treatment approaches can help you manage flare-ups and speed up healing. Talk to your dermatologist to understand which treatment option will be best suited for you.

In some cases, HS flare-ups can affect your emotional wellbeing. Mindfulness practices, talking to your dermatologist, spending time with family and friends, joining a support group, and meeting with a mental healthcare provider can all help you cope. Living with HS may not always be easy, but an effective treatment plan and support system can significantly improve your experience.

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