Hidradenitis suppurativa, also known as acne inversa, is a skin condition characterised by large, persistent abscesses or boils that appear under the skin, typically in the armpit, perianal, breast fold and genital regions. These lesions are very painful, become infected and often rupture.
In addition to physical symptoms, hidradenitis suppurativa is associated with profoundly negative impacts on quality of life, mental health, social interaction and sexual function.
While the exact triggers of hidradenitis suppurativa are unknown, it typically appears at the onset of puberty, and occurs more in women than men, suggesting hormonal involvement. This is likely why many female patients report aggravations of their hidradenitis suppurativa prior to their menses as reproductive hormones fluctuate.
The affected skin areas (armpit, breast fold, genital and perianal regions) have dense amounts of apocrine glands, which are small structures attached to a hair follicle that often secrete skin oils.
These apocrine and follicular structures are affected by hyperkeratosis (thickening of the outer layer of skin by a protein called keratin) which blocks the outlet of the gland, creating congestion/blockage, inflammation and a favourable environment for bacteria to thrive.
A number of factors can contribute to acne inversa, however as each person is unique, factors involved in one person's acne inversa can be completely different to another person's. Following is an overview of these factors that our skin health practitioner Rebecca considers to determine what might be playing a role in each person's skin issue.
There are a number of known risk factors associated with acne inversa, with a higher incidence in people who:
Autoimmune related inflammation and activity is involved in some types of hidradenitis suppurativa, with 17% of patients with Crohn’s disease experiencing the condition. In this scenario, the immune system dysregulation is what’s thought to cause an exaggerated and chronic inflammatory response. This means the immune system isn’t able to deal appropriately with the bacterial infection that occurs at the site of boils.
If the acne inversa is autoimmune in nature, often underlying autoimmunity is suboptimal digestive health, typically with a disrupted gut microbiome - the colony of bacteria, yeast and fungi that live in the digestive tract and play a role in nutrient absorption and creation, as well as a healthy immune response. Often, patients with acne inversa are prescribed several rounds of antibiotics to treat the bacterial infection in the skin, which can disrupt the microbiome, with 64% of patients on antibiotic treatment often experiencing of digestive disturbances, and for women, 35% can experience vaginal candidiasis - a key sign of microbiome disruption in the vaginal canal.
98% of patients with hidradenitis suppurativa smoke, particularly in more severe cases. Nicotine can cause increased activity of sweat glands, and can impact the movement of immune cells responsible for managing infections, which could be partly responsible for ongoing infection. In some lab studies, nicotine has also been shown to promote the thickening of the skin and subsequent blockage of follicles that cause hidradenitis suppurativa.
Known toxins in cigarettes like polycyclic aromatic hydrocarbons compromise detoxification pathways, particularly those involved in the metabolism of the hormone oestrogen which has been implicated in the condition. Compromised detoxification pathways can lead to a higher body burden of other toxins that are known endocrine disruptors, and can directly or indirectly promote inflammation which exacerbates this inflammatory condition.
The sites where acne inversa occurs are close to lymph glands that form the lymphatic system, a key pathway of detoxification that is often dubbed the ‘drainage system’ of the body, given it’s responsible for clearing out unwanted substances from tissues, including white blood cells involved in infections.
Unlike the cardiovascular system that has a pump (the heart) to circulate blood and substances around the body, the lymphatic system relies on the contractile force of muscles and other tissues that come with movement to work. An efficient lymphatic system is necessary to not only remove processed toxins from the body - it’s also needed to clear out infections. Hence those living a sedentary lifestyle can have poor lymphatic drainage, which may make the removal of infections in the boils challenging.
The condition is often associated with other conditions, and complications if left untreated, such as:
Living with this painful condition carries a mental and emotional burden that often results in depression and sexual dysfunction that often need to be treated concurrently.
Sadly, many people with acne inversa avoid seeking medical care because of shame or embarrassment, and in particular, concern that it’s an STD for those who experience boils in the genital regions. However, as skin health practitioner Rebecca Hughes says ‘The sooner you get a diagnosis and start treatment, the quicker and better the outcome without the risk of more serious issues cropping up’.
Because acne inversa often shows up in the perianal and genital areas, people experiencing abscesses in these regions are prone to think it’s a sexually transmitted disease, however this isn’t true. This is why acne inversa isn’t something to be ashamed of, and seeking medical diagnosis from a GP or gynaecologist should be sought straight away.
A common misconception is that acne inversa is like acne (Acne Vulgaris), yet there are key distinctions between the two conditions. Acne vulgaris is driven by hormonal fluctuations in oestrogen or testosterone, whereas acne inversa isn’t necessarily hormonally directed, and often has an autoimmune component that drives the inflammatory response. In acne inversa, the boils appear in regions like armpits and groin, whereas acne vulgaris presents on the face, chest or back. While acne vulgaris pimples tend to come and go, acne inversa form painful boils that will persist until they rupture. Some boils can suppurate (burst), and some are hard inflamed nodules that get bigger or smaller.
In Australia, typical first line medical treatment is to relieve symptoms and includes:
Drug therapy in hidradenitis suppurativa is generally long term, which introduces the risk of adverse events related to the medicines or techniques. For example, as mentioned earlier, gastrointestinal disturbances and vaginal candidiasis are reported with long term antibiotic therapy.
Biological therapy (e.g. immunomodulators and monoclonal antibodies) are designed to help the condition by lowering inflammation which unfortunately also suppresses the immune system, leading to an increased risk of opportunistic infections. This can be unhelpful if the lesions are prone to bacterial infection, which can lead to chronic infection.
The deleterious effect of antibiotics on human microbiome diversity is well recognised, and in turn negatively impacts immune defence as well as inflammatory modulation – both critical functions in the development of hidradenitis suppurativa.
Topical cortisone reduces inflammation at the site, however long term use of steroids is linked with contact sensitisation, dermal skin infections, topical steroid withdrawal syndrome (TSW) and thinning of the skin.
Finally, surgical treatments are employed in advanced cases of hidradenitis suppurativa. Removal of lesions through a procedure known as wide angle excision is an invasive procedure, involving slow healing times that employ grafting and granulation techniques.
Research has found people with the ‘atopic triad’ have a defective barrier of the skin and upper and lower respiratory tracts.
These genetic alterations cause a loss of function of filaggrin (filament aggregating protein), which is a protein in the skin that normally breaks down to create natural moisturisation and protect the skin from penetration by pathogens and allergens.
Filaggrin mutations are found in approximately 30 percent of people with atopic dermatitis, and also predispose people to asthma, allergic rhinitis (hayfever), keratosis pilaris (dry rough patches and bumps on the skin), and ichthyosis vulgaris (a chronic condition which causes thick, dry, scaly skin.)If one parent carries this genetic alteration, there is a 50 percent chance their child will develop atopic symptoms. And that risk increases to 80 percent if both parents are affected.
The connection between the gut microbiome and skin health is complex, however, research has found the microbiota contributes to the development, persistence, and severity of atopic dermatitis through immunologic, metabolic and neuroendocrine pathways.
Deficiency of Omega-6 essential fatty acids (EFA) has been linked with the increased incidence of atopic dermatitis, along with the inability for the body to efficiently metabolise EFA’s to gamma linoleic acids (GLA) and arachidonic acids (AA).
Changing weather conditions can certainly aggravate eczema symptoms, but the triggers are subject to change among individuals.
Mould exposure and susceptibility to mould can cause Chronic Inflammatory Response Syndrome (CIRS), of which dermatitis is a manifestation.
Our skin health practitioner Rebecca Hughes helps patients with acne inversa address their unique causes and contributing factors so they can resolve these painful lesions for good. This starts with a comprehensive assessment of a patient's health, including:
Functional testing may be suggested to help identify the factors contributing to hidradenitis suppurativa and may include:
Follow investigation, a personalised, holistic hidradenitis suppurativa treatment plan will be formulated, and with the support of a health coach - an expert in behaviour change - patients will implement a plan that may include:
Are you ready for a personalised, natural functional medicine treatment? Our unique model of care was designed with you in mind. Find out how here, then book a call today!
(Leanne is a real patient but we’ve changed her name and image to protect her privacy)
Leanne was 25 when she came to see us and had been experiencing hard nodules in her groin since her teens. These fluctuated from mild to severe with her menstrual cycle. Antibiotics and the pill were prescribed, but Leanne had an adverse reaction to both.
Read Leanne's story by hitting the button below
At Melbourne Functional Medicine, we’ll work with you to detect and treat the root cause of your acne inversa so clear skin can be yours again, using our investigative, supportive, and personalised approach to your skin health.
Are you ready for a personalised, natural functional medicine treatment for your skin? Our unique model of care was designed with you in mind. Find out how by clicking the button below.
While stress isn’t a cause, the mental and emotional toll of having hidradenitis suppurativa can lead to stress, which has direct and indirect influences on many factors that contribute to the condition, like sex hormones (oestrogen), chronic inflammation, and autoimmunity.
There are many possible nutrient interventions used to treat hidradenitis suppurativa, which are personalised based on an individual’s needs. For example, nutrients like zinc and vitamin A are needed for skin repair; vitamin D helps with regulating the immune system to help normalise the inflammatory response; chromium is used for regulating glucose and insulin insensitivity that’s often a factor in hidradenitis suppurativa; and the mineral selenium might be prescribed for autoimmune regulation.
It’s often believed that applying antibacterials to the affected areas will help, however it is bacteria under the skin that is causing the infection, rather than on the skin surface. Also, tea tree oil should never be applied to an open wound - it will burn the skin and be very painful. The best thing to do if a boil bursts is to apply a silver lined dressing to protect it from further bacterial infiltration.
It’s a common misconception that bacteria on the skin cause hidradenitis suppurativa, when the reality is that they are caused by a blockage in the skin follicles, with the bacterial infection being under the skin versus on the skin surface, and secondary to the follicles blocking. Therefore hidradenitis suppurativa is not caused by poor hygiene, and applying a topical antibacterial like coconut oil will not help.
The best approach to solving hidradenitis suppurativa is to seek a holistic treatment that addresses the underlying immune dysfunction or inflammation, like the functional medicine approach. If a boil bursts, applying silver lined dressing to protect the wound is the best approach to protect from further bacterial infiltration.
Relapses after conventional treatment with drugs like antibiotics are common, and the condition doesn’t go away easily. Often in these cases, lancing the boil is done, and if it returns, surgical incision is conducted to remove the entire boil. However, using the functional medicine approach that seeks to address the underlying factors has shown to reduce the chance of them recurring.
Our functional medicine practitioner often uses herbal treatments to target each risk factor where relevant. Therefore the approach is personalised, and can include:
Can’t find what you’re looking for? Reach out to the team directly – we’ll be happy to assist.