Hydradenitis suppurativa or Verneuil’s disease

Diagnosis

The diagnosis is based on the presence of typical lesions (nodules, abscesses, fistulas, fibrous scars and open comedones), their typical location (axillary, mammary, inguinal and perineo-gluteal regions) and their chronic and recurrent nature.

1. Anamnesis:

• Family history: The disease can be hereditary, so it is important to check if there are similar cases in the family.
• Symptom history: Patients often report painful, recurrent nodules, sometimes accompanied by abscesses, which have been evolving for several months or years.
• Recurrence of abscesses: Frequency and number of inflammatory flare-ups, as well as the duration of episodes.
• Pain and functional impact: Patients often describe severe pain that may restrict their movement or activities.
• Treatment history: Treatments already used (antibiotics, surgery, etc.) and their effectiveness.
• Aggravating factors: Obesity, smoking, and link to menstrual cycles or hormonal fluctuations.

2. Inspection of skin lesions:

Physical examination reveals several types of lesions characteristic of suppurative hydradenitis:

• Subcutaneous inflammatory nodules: These painful lesions often appear in the armpits, groin, buttocks, perianal area or under the breasts.
• Painful abscess: Abscesses can be open or closed. They are often recurrent and sometimes become secondarily infected.
• Fistula: The formation of channels connecting the surface of the skin to deep abscesses is a hallmark of advanced disease. These fistulas can drain pus.
• Scars: With the chronicity of the disease, thick or fibrous scars form, sometimes with sinuous tracts under the skin.
• Blackheads: Frequent presence of multiple or double blackheads in affected areas.

3. Location of lesions:

• Characteristic regions: Hydradenitis suppurativa mainly affects areas rich in apocrine sweat glands, such as:
  • The armpits.
  • The eldest.
  • The perianal region.
  • The buttocks.
  • Under the breasts in women.
• Symmetry of lesions: The lesions are often bilateral.

4. Palpation:

• Pain on palpation of nodules and abscesses: Sensitivity is often high, especially during acute flare-ups.
• Presence of subcutaneous tracts: Palpation can detect underlying fistulas or sinuses formed under the skin.

5. Severity Assessment:

Several tools are used to assess the severity of hydradenitis suppurativa, including the Hurley classification:

• Stage I (mild form): Presence of isolated nodules, without fistulas or scarring.
• Stage II (moderate form): Recurrent lesions with abscess and fistula formation, but with areas of relatively healthy skin between lesions.
• Stage III (severe form): Presence of multiple interconnected abscesses and fistulas, affecting large areas of the skin, with significant scarring and complex fistulas.

Laser hair removal and Verneuil’s disease

Laser hair removal can be beneficial in the management of hydradenitis suppurativa (Verneuil’s disease) for several reasons, mainly because of its impact on hair follicles, which play a key role in the development of inflammatory lesions. Here are the main benefits of laser hair removal in the treatment of this disease:

1. Reduction of inflammation :

• Hydradenitis suppurativa is often triggered by obstruction of the hair follicles, followed by inflammation of the sweat glands. Laser hair removal targets these follicles, partially or totally destroying them, reducing the likelihood of their blockage and, therefore, inflammation.
• By eliminating hair growth in at-risk areas (armpits, groin, buttocks), mechanical irritation due to traditional shaving or hair removal is reduced, which reduces the risk of microtrauma that promotes abscesses.

2. Reduction of recurrences :

• Laser hair removal, by removing hair and hair follicles, can limit the development of new inflammatory lesions. This is especially helpful in patients with frequent recurrences.
• Studies have shown that laser hair removal can reduce the frequency and severity of flare-ups, especially in areas where apocrine sweat glands are numerous.

3. Reduction of secondary infections :

• By reducing the presence of hair, there is less chance of sweat and bacteria accumulating in the follicles, which decreases the chances of secondary infection of abscesses.
• Fewer hairs also mean fewer entry points for bacteria, which can help prevent superinfection of lesions.

4. Alternative to other forms of traumatic hair removal :

• Traditional hair removal methods (such as shaving or waxing) can cause skin trauma, worsening inflammation in patients with hydradenitis suppurativa. Laser hair removal, by eliminating the need for regular shaving or waxing, reduces this repeated irritation.

5. Pain reduction and improved quality of life :

• By reducing the number of inflammatory lesions, painful nodules, and abscesses, laser hair removal can help reduce the pain and discomfort associated with the disease. This can improve patients’ quality of life, both physically and psychologically.

6. Types of lasers used :

• Nd-YAG Laser: This laser is often preferred for hair removal in patients with suppurative hydradenitis due to its ability to penetrate deeper into the skin, allowing hair follicles to be better targeted while reducing the chances of complications for darker skin tones.

7. Progressive and sustainable results :

• Laser hair removal usually requires several sessions to achieve a significant reduction in hair. However, once the follicles are sufficiently damaged, regrowth is reduced, which decreases the chances of new flare-ups in the long term.

8. Limits and precautions :

• Complementary treatment : Laser hair removal is often a complementary treatment to other medical procedures (such as antibiotics, surgery, or immunosuppressants). It is not a substitute for disease-modifying medical treatments for hydradenitis suppurativa.
• Scars and open lesions : Laser treatment may not be appropriate if the area to be treated has active lesions or open abscesses. In these cases, it is necessary to treat the acute inflammation first.
• Risk of pigmentation : In patients with dark skin, there is a risk of changes in pigmentation after laser hair removal. A laser adapted to their phototype is therefore crucial.

In short:

Laser hair removal has several advantages in the management of hydradenitis suppurativa, reducing inflammatory flare-ups and secondary infections while decreasing skin irritation due to conventional hair removal methods. Although it does not cure the disease, it helps to reduce its impact and improve the quality of life of patients.

Etiology

The etiology of hydradenitis suppurativa (or Verneuil’s disease) is still poorly understood, but it is considered multifactorial, involving genetic, immunological and environmental elements. The main etiological factors identified are:

1. Genetic factors:

• There is a genetic predisposition to hydradenitis suppurativa. About one-third of patients have a family history of the disease, suggesting a hereditary link. Mutations in genes related to inflammation or immune responses may play a role.

2. Obstruction of hair follicles:

• One of the main etiological theories is that the disease begins with an obstruction of the hair follicles in areas rich in apocrine sweat glands (armpits, groin, buttocks, under the breasts). This obstruction causes the follicles to rupture, causing an inflammatory reaction and the formation of nodules and abscesses.

3. Abnormal immune response:

• Hydradenitis suppurativa is associated with a dysfunctional immune response. Patients often present with chronic inflammation with overexpression of certain pro-inflammatory cytokines (such as tumor necrosis factor-alpha – TNF-α). This immune hyperreactivity leads to the formation of inflammatory skin lesions.
• Inflammation can also promote the formation of fistulas and significant scars.

4. Hormonal imbalances:

• Verneuil’s disease occurs mainly after puberty, which suggests a hormonal influence. Sex hormones, especially androgens, may play a role in the activation of apocrine glands and the modulation of the inflammatory response.
• Women are more frequently affected, and the condition can worsen during menstrual cycles or pregnancy.

5. Environmental and lifestyle factors:

• Smoking: Smoking is strongly associated with suppurative hydradenitis. It is considered a major risk factor, probably due to its effect on skin microcirculation and inflammation.
• Obesity: Obesity is an aggravating factor. Excess weight leads to increased friction of the affected areas, exacerbating inflammation.
• Hygiene and skin friction: Although the disease is not due to a lack of hygiene, rubbing of clothing or skin folds can aggravate the lesions.

6. Skin microbiome:

• Patients with hydradenitis suppurativa often have secondary bacterial colonization, especially by Staphylococcus aureus or Streptococcus, but bacteria are not the direct cause of the disease. However, bacterial infections can aggravate existing abscesses.

In summary, suppurative hydradenitis is likely due to a complex interplay between genetic predispositions, hormonal factors, an exaggerated immune response, and environmental factors such as smoking and obesity. This combination of factors leads to chronic and recurrent inflammation of the hair follicles and sweat glands.

Treatments

Treatment is difficult and non-consensual. It depends on the extent of the existing damage and the inflammatory/infectious evolution expressed in the frequency of exacerbations, pain, suppurations and the patient’s expectations. In the vast majority of cases, it will be interesting to refer the patient to a dermatologist and sometimes to a visceral surgeon as part of a multidisciplinary treatment.

Since hydradenitis suppurativa is a chronic disease, treatments aim to control symptoms and reduce inflammatory flare-ups.

1. Medical treatments:
   • Antibiotics (oral or topical) to treat and prevent infections. Local treatments such as antiseptics and antibiotics are not very effective because of the depth of the lesions. General antibiotic therapy based on a combination of amoxicillin-clavulanic acid (1g 3 times a day) or pristinamycin (1g 2 to 3 times a day) should be used to treat flare-ups and try to stop the progression of nodules into abscesses. Long-term treatment with doxycyline (100 to 200mg per day) for anti-inflammatory purposes can delay recurrences.
   • Retinoids (vitamin A-derived drugs) to decrease inflammation.
   • Immunosuppressants (such as TNF inhibitors) for more severe cases.
   • Anti-inflammatories to control pain and inflammation.
2. Surgery:
   • Incision and drainage of abscesses. Incision and drainage of abscesses can also be performed. It is a simple gesture, which does not require hospitalization. It allows the evacuation of pus and temporary pain relief. However, it does not prevent recurrences. They often lead to abnormal healing with a fistulous path that can promote the chronicization of lesions. A complementary “cold” excision procedure must most often be performed.
   • Surgical excision of affected tissues in severe and recurrent forms. This may include removal of the affected sweat glands.
   • CO2 laser to remove stubborn lesions.
3. Lifestyle modifications: Emphasis must be placed on hygienic and dietary measures aimed at aggravating factors: overweight/obesity and smoking.
   • Weight loss and quitting smoking can reduce the severity of symptoms.
   • Rigorous hygiene and loose-fitting clothing to reduce skin irritation. Maceration should be avoided by adopting strict hygiene, careful drying of folds and wearing loose, cotton underwear. Long car journeys, especially in summer, prolonged sitting without mobilization are not recommended. Deodorants, especially sticks and balls that are used with heavy pressure on the armpits, shaving and waxing are usually not recommended (low-level evidence).

The primary role of the general practitioner is to explain the disease and its foreseeable course. There are associations and organizations (RésoVerneuil, Soldiarité Verneuil, etc.) where the patient can find additional explanations and support.