Hidradenitis and Pilonidal Disease

About Hidradenitis Suppuritiva

Hidradenitis suppuritiva (HS) is a disease manifested by skin infections which most commonly occur in the groins and armpits, but can also occur in the gluteal area and around the anus. It is caused by infection in specific apocrine glands which are the type of glands that secrete scents. These glands do not start functioning until puberty.

In patients with HS, infections occur in these apocrine glands which manifest themselves as skin infections. There can be overlap in symptoms between pilonidal disease and HS, and it is possible for a patient to have both problems at the same time. It is not clear if one predisposes to the other.

Pilonidal disease is caused by the shape of the gluteal crease, and is discussed elsewhere on this website. HS is caused by repeated infections in the apocrine glands and it is believed to have an autoimmune cause; pilonidal disease does not.  It is not clear if the body is attacking the apocrine glands themselves, or attacking the normal skin bacteria associated with these glands. There is a genetic predisposition to HS, and it is found in association with other autoimmune diseases, such as Lupus, and severe acne.

Hidradenitis Suppuritiva is treated in several ways:

  • Active skin infections can be surgically drained or removed.
  • In severe cases the entire apocrine gland bearing area of the skin can be surgically removed.
  • Long term administration of topical or oral antibiotics. Most commonly used is topical clindamycin or oral doxycycline.
  • Certain other medications can be used in more severe situations, such as spironolactone, metformin, oral contraceptives, and others.
  • Laser surgery.
  • Medications to blunt the immune response.
  • Functional medicine evaluation for environmental autoimmune triggers. (If you are interested in learning more about what Functional Medicine is about, this video link explains more: About Functional Medicine on the Today Show)

How does this affect pilonidal surgery?

HS and other autoimmune diseases have a significant effect on post-operative wound healing. We see slow healing, minor or major wound separations, and severe suture reactions in patients with HS. We are seeing some sort of healing problem in about 80% of our cleft lift patients. In general, we have found the cleft lift procedure to ultimately be successful in HS patients, but with a significantly more difficult postoperative course, with wider and more irregular and prominent scars, and with recurrent skin infections in the months and years after surgery which are usually related to the HS, but can confuse the situation. These problems are not unique to the cleft lift procedure, and HS patients can have problems after any of the operations for pilonidal disease.

A difficult issue is differentiating HS from pilonidal disease. If a patient’s infections are from HS, a cleft lift is not necessarily the answer, and may predispose to further problems. There are times when we see patients who had failed pilonidal surgery, and there is concern that the original diagnosis was incorrect – and the patient actually had HS rather than pilonidal disease.

In general, in any patient on Humira, prednisone (or any of the medications used to blunt the immune system) it is recommended that the medications be discontinued both before and after any kind of surgery because it creates a risk of infection and slows healing. But, in some situations it actually may be better to continue the medications to prevent post operative problems. At our clinic we evaluate this on a case-by-case basis.

It is our recommendation that any patient with HS take a two pronged approach to treatment. We feel that they should have a dermatologist help with the diagnosis and treating the symptoms, but also have an autoimmune evaluation by an Functional Medicine physician. Even though a patient may have a genetic predisposition to these autoimmune diseases, if certain diet or environmental triggers can be determined and removed, there are times when the disease itself can be eliminated. The process of diagnosis and treatment of this problem can take months or years. Optimally, this is accomplished before pilonidal surgery is performed, but often this is not feasible.

If you have cleft lift surgery at our clinic, we may want you on an oral tetracycline for a prolonged period of time post-operatively to prevent wound problems.