Q For five years now I've had a skin condition called hidradenitis. I've been admitted to hospital 24 times to have abscesses lanced but, within a few months of each treatment, the abscesses recur. I am almost constantly on antibiotics, which I feel I am immune to by now, having been on them for so long. I now need a ring cushion to sit on as I have so much scar tissue that it is uncomfortable to sit down; also, my mobility is being affected. - Sheila, via e-mail
A You are not alone. Hidradenitis suppurativa (HS) - to give it its full and proper medical name - affects an estimated 2 per cent of the population (Expert Opin Pharmacother, 2004; 5: 1767-70). It mostly affects young women and is rarely seen after the menopause. It appears to be linked to hormones (Women's Health in Primary Care, 2000; 3: 535-43).
Simply put, hidradenitis is inflammation of the apocrine sweat glands in the skin around the anus, armpits and genitals, resulting in chronic abscesses or sinuses. These inflammatory lesions are generally seen in skinfold areas such as the inguinal area, beneath the breasts, and on the buttocks, scalp, eyelids and behind the ears. As you are already aware, it's a painful, potentially disabling condition with a profound impact on quality of life.
It has no known cause and is notoriously difficult to treat. The fact that there's little disease-specific information and, thus, unclear classification and no standardised diagnosis no doubt contributes to this unhappy situation.
The wounds are difficult to heal, and HS sufferers report an unrelenting process of flare-ups, scarring and remission that can span decades.
To stop the inflammation, practitioners typically resort to surgery to remove the involved sweat glands. But, as this leaves scars and may have complications, other treatments - including antibiotics and lesion-drainage procedures such as lancing, as you've already mentioned - are usually tried first.
But there may be other options. As hormones (specifically androgens) are involved in HS development and activity, there may be a connection with polycystic ovarian syndrome (PCOS) or insulin resistance. PCOS is related to androgen which, in turn, can lead to acne vulgaris and related conditions like hidradenitis (Br J Surg, 1988; 75: 972-5). Also, the fact that HS often first appears with the onset of puberty underscores this androgen connection (Clin Exp Dermatol, 2001; 26: 501-3; Br J Dermatol, 1993; 129: 447-8). So, if you haven't already, ask your doctor to test for PCOS and insulin resistance, as you may need to treat these underlying conditions first.
Although many women report success in regulating hormones with the Pill, Dr Harald Gaier, naturopath and WDDTY panel member, suggests the following herbal remedy instead: take a tincture of Vitex agnus castus berries (20 drops/day in water) for eight months. But make sure that the tincture is from the berries, and not the easy-to-find product made from the leaves, stems and roots of the herb (such as the one made by Bioforce). Only this form of tincture has a regulating effect on ovarian hormones.
Regardless of your hormonal status, you may be better able to manage your condition by taking the following steps towards better wound care:
* Try manuka honey, especially in the high-viscosity, sterile Medihoney Antibacterial Gel, which also acts as a protective barrier. This has a good track record of solid scientific investigation behind it (J Wound Care, 1999; 8: 161-4; J R Soc Med, 1999; 92: 283-5; Nurs Stand, 2000; 15: 63-8), and is an effective remedy against drug-resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). It is available here in the UK, although it is manufactured and was researched in Australia. It also quickly removes the malodorous smell of any infected discharge and significantly reduces the risk of further bacterial colonisation.
* Try tea tree oil (or lemon juice, if you're hypersensitive to tea tree), applied neat to the infected area. Tea tree oil soap can also help to reduce the burning and itching.
* Increase the appropriate vitamins and minerals in your diet to boost wound-repair time and improve the results. Stock up on antioxidant vitamins A and C, the enzyme bromelain and the amino-sugar glucosamine to support skin and collagen formation, and immune function. Also, ensure that your diet contains adequate protein (Altern Med Rev, 2003; 8: 359-77).
* Aloe vera (oral and topical), cod liver oil (topical) and the essential oil of Ocimum gratissimum, a type of basil (topical), have all been proven to promote wound healing - at least in animals, which may not apply to humans (J Am Podiatr Med Assoc, 1989; 79: 559-62; Scand J Plast Reconstr Surg Hand Surg, 2000; 34: 15-20; J Wound Care, 2003; 12: 331-4).
* Try these hints and tips from the HS support group HIDE (Hidradenitis Information Development Exchange, found at http://www.angelfire.com/amiga/hssg/):
* Always wear loose cotton clothing
* Avoid wearing any underwear garments whenever possible
* Keep a plant-spray bottle in the fridge filled with saline solution for reducing itchiness
* Don't use antiperspirants/deodorants (not even 'sensitive' ones) as these can irritate the skin and cause a flare-up
* Reduce or cease any activity that makes you sweat too much
* Sunlight exposure can help
* Using a paraffin-based gauze (such as Jelonet) can stop the wound dressings from sticking.
Lesion drainage has no effect on stopping recurrences so, if all else fails, the most successful surgical procedure is wide local excision, which removes all of the apocrine glands in the affected area. However, recovery is lengthy and painful, and the prognosis is uncertain. One study had a recurrence rate of only 27 per cent, although limited excision has had a success rate of almost 43 per cent (Int J Colorect Dis, 1998; 13: 164-8).
Recurrences may depend on site. Armpit surgery was followed by only a 3 per cent recurrence whereas surgery beneath the breasts saw a recurrence in half the cases. In 25 per cent of patients, lesions cropped up at another site after the operation (BMJ [Clin Res Ed], 1987; 294: 487-9).