Hidradenitis Suppurativa – a paradigm shift

A/Prof. Pablo Fernandez-Peñas was invited to Taiwan and Singapore to review the new concepts in Hidradenitis Suppurativa (HS). This is “a chronic, inflammatory, recurrent, debilitating, skin disease that usually presents after puberty with painful deep seated, inflamed lesions in the apocrine gland-bearing areas of the body, most commonly the axilla, inguinal and anogenital region” J Eur Acad Dermatol Venereol 2009;23:985-98. It is the classical “unknown” or “orphan” disease that most doctors misdiagnose as boils or abscesses and consider an infection or a surgical problem. Contrary to the common belief, HS is an inflammatory condition, that may be linked to the autoinflammatory syndromes. It may be due to commensal bacteria (the cutaneous microbiome) eliciting an inflammatory response in a genetically susceptible individual. It is not an infection, at least in the classical concept of infection (although lesions get infected frequently). The presence of pus is due to the excessive accumulation of blood white cells (neutrophils) in response to a trigger. The consequence of the inflammation is the development of abscesses, nodules, and fistulas that lead to severe scarring in armpits and groins.
HS has a huge impact in the quality of life of patients, worse than severe psoriasis, and is associated to a range of co-morbidities (other diseases) such as Obesity, Smoking, Depression, Fatigue, Hypertriglyceridemia, Diabetes, Crohn’s disease, Arthropathies and Cancer.
Due to the problems in diagnosis, we do not know how frequent the disease is. Usually patients are diagnosed late (average of 7 years from the first sign), the mean age of onset is 22 years, and last for at least 20 years (although the course is variable, with some patients only having mild disease).
At Westmead Hospital, we have been involved in a clinical trial using adalimumab as a treatment, and we have a clinic to review and follow-up patients with HS.