Hidradenitis Suppurativa

What is Hidradenitis Suppurativa?

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease with deep-seated nodules, abscesses, draining skin tunnels and scars, mostly in skin folds.^{[1, 2]} It is also called acne inversa, although it is not ordinary acne.

It usually starts in the second or third decade of life, and about 1 in 100 people are thought to have it.^{[2, 3]} For a condition like this, we ask that you are under a physician's care for it and that your treating team knows you are receiving complementary care.

Common symptoms

HS causes painful lumps and abscesses that can burst and drain pus. They most often occur in the armpits, groin, buttocks, genital area and under the breasts.^{[1, 2]} Over time, tunnels and scars can form.^[1]

Pain, drainage, odor and scarring can be hard to live with, and the condition can affect sleep, relationships and work.^{[1, 3]}

Causes and risk factors

The cause is not fully understood. Lesions appear to begin with blockage of hair follicles, followed by an immune response in which inflammatory signals such as TNF, IL-1β and IL-17 play a major role.^{[2, 4]} A genetic tendency, smoking, obesity and hormonal factors are established contributors.^[3]

Other conditions often occur alongside HS, including metabolic syndrome, inflammatory arthritis and inflammatory bowel disease.^[2]

How it is diagnosed and treated conventionally

HS is diagnosed by a clinician from the typical lesions, their locations and a pattern of recurrence.^{[4, 5]} Treatment depends on severity. It includes antibiotics, biologic drugs that block TNF (adalimumab) or IL-17 (secukinumab, bimekizumab) for moderate to severe disease, and surgery for scarred or tunneled areas.^{[2, 6]}

Lifestyle changes such as stopping smoking and managing weight are part of care.^{[3, 7]} A recent review advises early treatment to prevent permanent skin damage and attention to pain and related health problems.^[2]

Why Hidradenitis Suppurativa calls for a whole-person approach

HS is not only a skin problem. Chronic inflammation affects the whole body, and the condition carries a heavy load of pain, mood problems and sleep disruption.^{[2, 8]} Recent reviews describe the best management as personalized and shared among several kinds of clinicians.^[2]

The clinic's supportive care addresses these daily burdens. It does not treat the lesions and has not been shown to change the disease.

Systemic inflammation

HS involves immune pathways beyond the skin, and it often occurs with metabolic and inflammatory conditions.^{[2, 3]} This is why your dermatologist may check for other health problems.

Lifestyle factors

Smoking, obesity, alcohol and sleep problems are linked to more severe disease, and diets rich in vegetables, fruits and fish have been described as supportive. The evidence for diet is still developing.^{[7, 9]}

Mood

A meta-analysis of 28 studies found depression in about 21% of people with HS and anxiety in about 12%, with wide variation between studies. People with HS had about twice the odds of depression or anxiety compared with controls.^[8] Tell your physician if you feel low or anxious, because mood problems can be treated.

Sleep

A systematic review found that people with HS are more likely to have sleep disorders, and that many report poor sleep because of pain and itching.^[10]

Acupuncture as supportive care in Hidradenitis Suppurativa

What the research shows

We found no clinical trials of acupuncture for HS. Acupuncture has not been shown to heal lesions, reduce flares or change the course of HS.

For pain in general, an individual patient data meta-analysis of 39 high-quality trials (20,827 patients) found acupuncture was better than sham acupuncture and than no acupuncture for chronic musculoskeletal pain, osteoarthritis, headache and shoulder pain, with effects that lasted about a year. These are different conditions, and HS pain is partly from inflamed abscesses, so the findings may not apply.^[11]

How acupuncture may work

For HS, no mechanism has been tested. In general, acupuncture is proposed to influence how the nervous system processes pain and stress. The authors of the pain meta-analysis noted that effects could not be explained by placebo alone, but that factors beyond needle location also contribute.^[11] These are proposed explanations, not settled facts.

What treatment involves

Treatment uses fine, sterile, single-use needles, with sessions usually lasting about 20 to 40 minutes. A course of several visits is followed by reassessment of whether it is helping with pain, stress or sleep. Needles are placed away from active abscesses, open wounds and infected skin, on areas such as the hands, arms and legs.

In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[12] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker (relevant to electroacupuncture). Also tell us if you take biologic or other immune-suppressing medicine, or have any open or draining lesions.

Ayurvedic medicine as supportive care in Hidradenitis Suppurativa

The Ayurvedic view

Ayurveda has no classical name that matches HS exactly. Recurring boils and abscesses are traditionally described as involving Pitta and Kapha with impurity in the blood (rakta). These are traditional frameworks, not biomedical diagnoses.

Therapies that may be used

Care is individual and limited to gentle measures for the whole person:

• Diet and daily routine, such as regular meals and consistent sleep times, alongside the diet advice from your physician
• Stress-reducing practices such as breathing exercises and relaxation
• Individually prescribed herbs, only after review of your medicines

Panchakarma, the traditional cleansing program, is not appropriate during pregnancy, acute illness or frailty. HS involves open, draining skin and often immune-suppressing medicine, so we would not use it unless your treating physician agrees.

What the research shows

We found no clinical trials or systematic reviews of Ayurvedic medicine for HS, so any benefit is unknown.

Turmeric (curcumin) is an Ayurvedic herb that has been studied for inflammation. A meta-analysis of 66 trials found that turmeric or curcumin supplements lowered blood markers of inflammation such as CRP, TNF-alpha and IL-6.^[13] A systematic review of 12 studies of Curcuma in skin conditions suggested effects on psoriasis lesions and wound healing, and called for more clinical trials.^[14] None of this research was done in HS, and a change in a blood marker does not show that a skin disease improves.

Ayurvedic products also vary in quality. About one fifth of those bought online contained detectable lead, mercury or arsenic.^[15]

Herbal medicine as supportive care in Hidradenitis Suppurativa

Herbs and formulas that have been studied

We found no clinical trials of Chinese herbal formulas or other herbs for HS. Turmeric, discussed above, is the herb with the closest relevant research, and it is used in both Ayurveda and Chinese medicine.^{[13, 14]}

What the research shows

For HS itself, there is no evidence. The anti-inflammatory research on turmeric concerns general blood markers and other skin diseases, and the authors of the skin review said that more trials are needed to establish effective forms and amounts for different conditions.^{[13, 14]}

Herbs and supplements should not be used to replace antibiotics, biologic drugs or surgery, or to lessen the need for them.

Safety and herb-drug interactions

Herbs are active substances and can interact with medicines. A systematic review identified many herbs and supplements, including ginger, ginkgo and Chinese wolfberry, that may raise bleeding risk when taken with warfarin.^[16] A broader review described bleeding with danshen and ginkgo plus warfarin, and lowered levels of some immune-suppressing drugs with St John's wort.^[17] People with HS may take antibiotics, hormone treatment or biologic drugs, so each herb needs review by your prescriber.

Products should come from tested sources. Tell us if you are pregnant or breastfeeding or have liver or kidney disease. Do not apply herbal preparations to open or draining lesions without your dermatologist's approval.

Translating traditional medicine into modern biological language

This is interpretation, not equivalence. Chinese medicine would describe recurring abscesses with patterns such as damp-heat or toxic heat with blood stasis. Ayurveda would speak of Pitta-Kapha imbalance with impure blood.

Researchers instead study follicular blockage, immune signals such as TNF, IL-1β and IL-17, and the role of obesity, smoking and hormones.^{[2, 4]} No study has shown that a traditional pattern corresponds to any of these processes. What the traditions offer is a way to organize individual complaints such as pain, stress and poor sleep for supportive care.

How this care fits with your medical care

The clinic's role is complementary. We do not diagnose HS or treat the lesions, prescribe or change medicines, or replace your dermatologist. Do not stop or change antibiotics, biologic drugs or other prescribed treatment without your prescriber.

Please bring your diagnosis, a list of current and past treatments, and a full list of medicines and supplements. Tell us about the clinicians treating you so supportive care fits your plan.

When to seek urgent medical care

Some changes in HS need prompt medical evaluation.^{[1, 2]}

• Fever or chills with a painful, rapidly spreading red or hot area of skin
• A very painful new abscess that is growing quickly or not draining
• Severe pain, swelling or drainage around the anus or genitals
• Feeling very ill, faint or confused with a skin flare
• Thoughts of harming yourself. Call or text 988, the Suicide and Crisis Lifeline.^[3]

For emergencies, call 911 or go to the nearest emergency department.