Hidradenitis suppurativa
HS; acne inversa; Verneuil disease
Hidradenitis suppurativa is a chronic, recurrent, inflammatory dermatosis of apocrine-gland-bearing skin — axillae, groin, perineum, anogenital, sub-mammary, buttocks — characterised by painful inflammatory nodules, abscesses, sinus tracts and hypertrophic scarring. UK prevalence approximately 1%, with substantial diagnostic delay (average ~ 7 years). HS is staged by the Hurley system (I → III). Disease modifiers include smoking, obesity, metabolic syndrome and family history (familial HS in 30–40%). Management is multidisciplinary — antibiotics, biologics (adalimumab NICE TA392, secukinumab NICE TA935), surgical deroofing and wide excision. Skin-oncology relevance: chronic Hurley-III HS develops cutaneous SCC (Marjolin) in approximately 1–5% — aggressive, often perianal or perineal, and frequently fatal.
Clinical features
- Recurrent painful inflammatory nodules and abscesses in apocrine-rich sites — axillae, groin, perineum, perianal, anogenital, sub-mammary, buttocks, posterior thighs.
- Progression to sinus tracts, fistulae and hypertrophic / contracture scarring.
- Symptoms include malodorous discharge, restricted mobility, severe psychosocial impact.
- Onset typically post-puberty (peak 20–40); female predominance ~ 3:1; family history in 30–40%.
- Strong association with smoking, obesity, metabolic syndrome, IBD (particularly Crohn), depression.
Hurley staging
- Hurley I — single or multiple abscesses without sinus tracts or scarring.
- Hurley II — recurrent abscesses with sinus tracts and scarring, widely separated lesions.
- Hurley III — diffuse / near-diffuse involvement with multiple interconnected tracts and abscesses across an entire body region.
- IHS4 (International Hidradenitis Suppurativa Severity Score) used for treatment response monitoring.
cSCC risk in chronic HS
- Chronic Hurley-III HS — particularly perianal, perineal and gluteal — develops cutaneous SCC in approximately 1–5%.
- SCC arising in HS behaves aggressively — late presentation, high recurrence, regional lymph-node involvement common, significant mortality.
- Median latency ~ 15–25 years of chronic disease before SCC develops.
- Male, smoker, perianal Hurley-III disease are particular risk groups.
- Active surveillance — clinical examination of chronic plaque sites every 6–12 months; biopsy any new keratotic, ulcerated or rapidly growing area.
Management
- Lifestyle — smoking cessation, weight management, friction reduction (loose clothing, anti-perspirant alternatives).
- Topical — clindamycin 1% solution, benzoyl peroxide, resorcinol.
- Systemic antibiotics:
- Doxycycline 100 mg BD for 3 months.
- Clindamycin 300 mg BD + rifampicin 300 mg BD for 10 weeks.
- Ertapenem 1 g IV daily for severe flares.
- Biologics:
- Adalimumab — NICE TA392 for moderate-to-severe HS unresponsive to conventional therapy.
- Secukinumab — NICE TA935 for active moderate-to-severe HS in adults when adalimumab is not suitable, has not worked or has stopped working.
- Other systemic — hormonal (spironolactone, cyproterone), metformin, dapsone, oral retinoids.
- Procedural:
- Deroofing of sinus tracts.
- Wide local excision with healing by secondary intention or skin graft / flap reconstruction.
- Laser hair removal (long-pulsed Nd:YAG) for early disease.
- Pain control — substantial; multidisciplinary pain service.
- Psychological support — depression and anxiety prevalence very high; signpost / refer.
- Cancer surveillance — annual examination of chronic plaque sites; biopsy any new lesion.
References
- Ingram JR et al. UK guideline on the management of hidradenitis suppurativa. Br J Dermatol; 2018.
- Sabat R et al. Hidradenitis suppurativa. Nat Rev Dis Primers; 2020.
- NICE TA392. Adalimumab for treating moderate to severe hidradenitis suppurativa. London: NICE; accessed 18 May 2026. NICE TA935. Secukinumab for treating moderate to severe hidradenitis suppurativa. London: NICE; accessed 18 May 2026.
Spot a correction?
If any clinical statement, citation or link on this page needs updating, please email admin@skinoncology.net with the page name, the proposed correction and the supporting source.