Hidradenitis suppurativa is a chronic and possibly disfiguring skin condition, which leaves behind lumps, abscesses, and boils wherever the skin rubs together. Although anyone can develop it after puberty, it is widespread among women of reproductive age.
Does this sound familiar? For a gynecologist, it does: it matches the population affected by many other reproductive conditions, and in particular, polycystic ovary syndrome (PCOS). It turns out that it is not so rare for dermatological and hormonal health to coincide. For women affected by both hidradenitis and PCOS, long-term relief may require cooperation between specialties.
What is hidradenitis suppurativa (HS)?
Also known as acne inversa, hidradenitis suppurativa (HS) can cause a combination of lumps, cysts, nodules, blackheads, or boils in the armpits, buttocks, breasts, or wherever the skin rubs together.
These lumps are usually larger than regular acne, and can easily become inflamed or infected. When they do, they can leak pus or form sinus tracts – small channels under the skin that connect boils together. These could be painful enough to interfere with movement, and may even develop a foul odor. As they often reappear in the same regions, HS can also lead to severe scarring.
When left to progress, HS can impact a woman’s self-esteem and overall quality of life. This is why the treatment of hidradenitis suppurativa should focus on healing the lesions with as little scarring as possible and preventing any future flare-ups.
What causes hidradenitis suppurativa?
Originally, dermatologists believed HS stemmed from a problem with the oil-producing sweat glands in the armpits and groin, which were simply more prone to clogging for some. Now it’s known that HS can appear in other areas, such as below the breasts, where we don’t have apocrine (oil-producing) glands. The American Academy of Dermatology (AAD) believes there are many possible causes behind the condition, including:
· Problems with skin immunity
· Inflammation near hair follicles
· Exposure to bacteria
· Genetic predisposition
In addition, people who smoke, are obese, or have any condition that affects their immune system (such as diabetes, lupus, or recovering from chemo) are also at higher risk of developing hidradenitis suppurativa.
HS versus regular acne
At first glance, HS can look a lot like a severe case of hormonal acne. In many ways, these skin conditions are remarkably similar: they often start when a hair follicle gets clogged and becomes inflamed. Furthermore, they both may involve similar pimples and blackheads.
However, there are some key differences between HS symptoms and acne:
- HS lesions usually involve the skin’s deeper layers, as opposed to acne’s superficial blemishes.
- In HS, hair follicles get generally clogged with keratin (a type of protein), rather than acne’s softer dead skin cells.
- HS lesions tend to be somewhat symmetrical, rarely affecting just one armpit or buttock.
About polycystic ovary syndrome
Affecting up to 10% of all women of childbearing age, PCOS is now one of the best-known hormonal conditions among women.
The main defining factors of polycystic ovarian syndrome are the presence of small cysts in the ovaries, as well as long-term hormonal imbalances. Women with PCOS generally have increased levels of “male” sex hormones, low levels of estrogen and progesterone, and irregular menstrual cycles.
No single trigger or cause for PCOS has been identified, but we know it usually appears alongside the following comorbidities:
· Type 2 diabetes
· Insulin resistance or metabolic syndrome (sometimes known as pre-diabetes)
· Hyperandrogenism (excess testosterone levels)
· Obesity
While not all female patients with PCOS have these hormonal conditions, they appear together often enough to make a link undeniable.
Women with PCOS are at a higher risk of developing infertility, heart disease, and difficulties with weight loss.
How are HS and PCOS related?
Several population-based studies show that the prevalence of PCOS among people with hidradenitis suppurativa is nearly twice as high as that of the general population. There is definitely a strong link, but many researchers are still unsure about its direction: is polycystic ovary syndrome causing HS? Is it the other way around?
Hormones and skin
The most likely explanation is that the risk for both conditions increases due to similar reasons. We already know that excess levels of testosterone in women (typically found in PCOS) can cause skin problems, such as hormonal acne, hirsutism (excess body hair growth), or seborrheic dermatitis (scaly skin patches). Many women report their HS flare-ups tend to happen at the same time of their menstrual cycle, especially right before menstruation, which further strengthens this relationship.
At the same time, the effects of chronic inflammation are important to consider. Women with PCOS often have constantly high levels of C-Reactive protein, a marker that indicates generalized inflammation. At the same time, this protein is also high among people with HS, especially right before a flare-up.
Comorbidities like type 2 diabetes or obesity can also make HS flare-ups more frequent. Such conditions also increase inflammation, impair immunity, and make any infection harder to heal — which could result in bigger or more abscesses.
Dermatology vs gynecology: how to fix your skin
When confronted with a flare-up, HS treatment should focus on healing the skin lesions. This is where a dermatologist should take point to determine the disease severity as well as rule out any infection. Medication may include topical antibiotic creams or antiseptic washes on the pimples or blackheads. If there are any bigger abscesses or if lesions are exuding pus, your doctor may also prescribe oral antibiotics.
Once that’s taken care of, a long-term plan to prevent the boils from reoccurring. After the initial flare-up of HS, it doesn’t hurt to screen for PCOS, insulin resistance, and diabetes. This is the time for teamwork: often, a dermatologist may need to refer you or coordinate care with a gynecologist, endocrinologist, or even an immunologist.
For women who have both HS and PCOS, controlling one often has a beneficial impact on the other. These PCOS treatment options are also commonly used to prevent hidradenitis flare-ups:
· Oral contraceptives (birth control pills), especially if the HS boils seem triggered by menstruation
· Anti-androgen therapy, such as spironolactone or finasteride, which can help lower testosterone levels
· Metformin, a medication used to lower blood sugar, especially among women who have also developed metabolic syndrome.
Managing both conditions long-term can be tough on a person’s mental health and their self-image. Pervasive weight gain, frequent acne, and unwanted hair growth are all typical symptoms of PCOS, and they directly target many “traditional” standards of femininity. At the same time, scarring and oozing from HS can cause many women to isolate or to be self-conscious about their bodies.
No holistic healthcare plan can be complete without addressing these issues. This may involve enacting long-term lifestyle changes that help control insulin levels, anti-stress techniques, and prioritizing anti-inflammatory foods.
Dr. Thais Aliabadi: A solid ally for your reproductive wellness
In her Beverly Hills practice, Dr. Thais Aliabadi runs one of the country’s top women’s health facilities. A combination of superb training, a “whole woman” approach to reproductive health, and a welcoming team help her nurture a deep relationship with each patient. She supports women of all health conditions through all phases of life.
Board-certified by the American Board of Obstetrics and Gynecology, Dr. Aliabadi has extensive experience coordinating care with colleagues from different specialties. This helps her design state-of-the-art treatment options for women with hormonal imbalances, which may impact anything from their self-image to their heart conditions or infertility.
We also invite you to establish care with Dr. Aliabadi. Please make an appointment online or call us at (844) 863-6700 for general inquiries.
The practice of Dr. Thais Aliabadi is conveniently located for patients throughout Southern California and the Los Angeles area, near Beverly Hills, West Hollywood, Santa Monica, West Los Angeles, Culver City, Hollywood, Venice, Marina del Rey, Malibu, Manhattan Beach, and Downtown Los Angeles, to name a few.
Sources
Hidradenitis Suppurativa Is Associated with Polycystic Ovary Syndrome: A Population-Based Analysis in the United States – Journal of Investigative Dermatology
https://doi.org/10.1016/j.jid.2018.01.009
Sex- and Age-Adjusted Population Analysis of Prevalence Estimates for Hidradenitis Suppurativa in the United States
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5710402
The influence of body weight on the prevalence and severity of hidradenitis suppurativa https://pubmed.ncbi.nlm.nih.gov/24577555/
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