What should I ask before surgery for my troubling skin ailment?

Conditions Expert Dr. Otis Brawley Chief Medical Officer,
American Cancer Society

Expert answer

Dear Joann:

Hidradenitis suppurativa, or HS, is a disease in which patients have flare-ups of skin nodules and blisters in areas of hormonally influenced sweat glands, including the sweat glands, of the armpit, breast and groin. It occurs frequently in patients who are obese. Puss-filled lesions under the skin may be evident in early stages. The lesions get infected and develop an odor, and there can be intense pain. It can be mistaken as acne or, in the groin, even herpes.

HS is seen in men and women. It rarely is seen before puberty. It is more common but not exclusive to people who are overweight and patients with pre-diabetes or metabolic syndrome. It is also more common in women with polycystic ovary disease. By some estimates, one in 25 adults have at least one episode of the disease. Most last a relatively short time, but a small number of people have ongoing episodes lasting decades. Patients who have flare-ups on and off are at increased risk of skin cancer. Those with ongoing outbreaks are best served by a dermatologist or plastic surgeon with an interest in this disease. One might try to find such a physician by contacting a university hospital or asking a doctor in your community for a referral. Only a skilled dermatologist or plastic surgeon who has examined you can answer your more specific questions.

There is no known medical or drug cure, but some useful treatments exist. In a few patients, surgical removal of the involved skin can be curative. No single treatment is effective in all patients. The goals of treatment are to (1) reduce the extent and progression of disease and bring it to a milder stage by healing existing lesions and preventing new ones from forming, and (2) promote regression of scars and sinuses (lesions tunneling under the skin), which can occur in more extensive disease.

Severity of HS is classified or staged according to what is known as Hurley's criteria 2 . These stages correlate with the common treatments.

Stage I: Single or a number of abscesses, without sinus tracts and scarring. Helpful drug therapies include antibiotics such as clindamycin lotion or oral erythromycin, hormones such as oral contraceptives or finasteride and the retinoids usually used as an acne treatment. Finasteride is Food and Drug Administration-approved for the treatment of benign prostatic disease and for male pattern balding. It has not been approved for HS and is definitely not to be used by a woman who may get pregnant while taking it. It may be difficult for women to get insurance to pay for it.

Stage II: Recurrent, multiple, widely separated lesions. This is best managed with drug therapy and limited surgery to remove or open up and drain lesions.

Stage III: Widespread involvement, or multiple connected abscesses, tunneling under the skin. These patients are treated with medical therapy and with wider, more aggressive surgical removal of the involved skin.

Experts whom I queried suggest:

• Wearing loose, breathable clothing with natural fabrics. Avoid tight clothing over the affected areas. Synthetic fabrics and tight-fitting clothing cause heat and perspiration, which can cause plugging of hair follicles and sweat glands.

• Using gentle antibacterial soaps and avoiding washcloths by using bare hands for cleansing.

• Avoiding antiperspirants, shaving and depilation if they irritate the affected areas.

• Losing weight and stopping smoking; these may decrease the number and severity of flare-ups.

There are reports that the use of a nondairy, low-glycemic load diet (sometimes called the Paleolithic, "Paleo" or "caveman" diet) can be helpful. This diet avoids products that obviously contain milk (milk, cheese, ice cream) as well as products derived from milk, such as casein, whey and milk solids incorporated into other foods.