Managing Hidradenitis Suppurativa (HS) in Black Skin

“I can’t overemphasize the significant physical and psychological impact of this disease and how it affects quality of life — the ability to have friendships, sexual relationships, and careers that thrive,” says Olayemi Sokumbi, MD, a dermatologist at the Mayo Clinic in Jacksonville, Florida. The physical effects of HS often lead to mental and emotional issues like depression and anxiety.

In practical terms, any Black person who has HS — or suspects they do — is likely to face unique challenges. If you’re one of those people, the best strategy is to educate yourself about the condition, find a dermatologist experienced in treating Black patients, and learn which medical and self-care options are available, so you can advocate for yourself and get the best care possible.

Because HS forms in hair follicles as well as apocrine glands, which secrete a type of sweat, the anatomy of those areas may come into play. “Hair follicles produce keratin, the main protein in hair. In patients with HS, keratin gets stuck within the hair follicle, plugging it,” Dr. Fernandez says, adding that because white and Black patients have different types of hair, “the different biology of the hair follicle could be the cause.”

Disparities in care may be involved, too. “Some of the difference in prevalence has been attributed to limited access to medical care,” says Jasmine O. Obioha, MD, a dermatologist at Cedars-Sinai in Los Angeles.

Treatment strategies for HS are basically the same for Black and white patients, but that may change with further research, says Sokumbi. Clinical trials have mostly been done on white patients, she explains, “so there’s a significant need for research on HS in Black patients to come up with therapies targeted to them.”

Meanwhile, for anyone managing HS, it’s a matter of merging medical treatment with self-care.

Medications that may be used to treat HS include the following:

• Antibiotics like topical clindamycin are often prescribed to treat mild hidradenitis suppurativa. For more severe cases, oral antibiotics can reduce inflammation and the bacteria that cause HS flare-ups.

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• Corticosteroid injections reduce inflammation when injected into a nodule, however, they don’t treat tunnels under the skin.

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  Short courses (less than three months) of oral steroids can also help reduce inflammation.
• Oral retinoids like isotretinoin and acitretin affect how skin cells grow and mature, and some small studies suggest that they may help diminish HS symptoms for some people.

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• Hormonal therapies like birth control pills that contain estrogen, spironolactone, cyproterone acetate, metformin, and finasteride can address hormonal issues that may play a role in HS.

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  They may reduce inflammation, regulate androgen (sex hormones, including testosterone) levels, and reduce flare-ups.
• Biologics are medications made from living organisms. They suppress the immune system and reduce inflammation. The biologics used for HS reduce inflammation, and research shows that some biologics can effectively treat hidradenitis suppurativa when other treatments fail.

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  Biologics approved by the U.S. Food and Drug Administration to treat moderate to severe HS include adalimumab (Humira), bimekizumab-bkzx (Bimzelx), and secukinumab (Cosentyx). Infliximab (Remicade), though not approved, is another biologic; it is given by infusion.

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It’s important to note biologics are strong medications and may not be right for everyone. Depending on how severe your HS is, your doctor may recommend you try other options first.

There are several surgical approaches for HS and determining which one is right for you depends on the extent and severity of your condition.

• Incision and drainage offers rapid but temporary pain relief; it has a 100 percent recurrence rate. After local anesthesia, an incision is made in a pus-filled HS lesion, which is then drained. But experts recommend a procedure called deroofing over incision and drainage. The same equipment is involved, and both require about the same amount of time.

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• Deroofing strips the “roof” or top part of a lesion or cluster of lesions, exposing the floor (or bottom) of the lesions. You will receive local anesthesia, and your doctor will remove the diseased tissue. The wound is then allowed to heal. Deroofing is the primary procedure for persistent nodules and tracts in Hurley stage 1 or 2 (mild or moderate HS). The rate of recurrence is estimated to be 27 percent.

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• Limited or localized excision involves the complete removal of the diseased tissue beyond the borders of activity, leaving behind clear margins. There’s a 22 percent rate of recurrence.

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• Wide excision is considered in severe HS cases. It involves the surgical removal of lesions as well as the surrounding disease-free tissue. It has a 13 percent rate of recurrence.

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• Laser therapy involves exposing HS lesions to a carbon dioxide laser to remove them.

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  Because hair follicles can play a part in HS symptoms, some people may benefit from laser hair removal in the early stages of HS.

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• Surgical removal and grafting may be recommended in severe cases of HS. This involves removing the most affected areas of skin and getting a skin graft to replace the skin and close the wound.

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While your dermatologist provides vital insight for guiding your HS treatment, there’s more you can take into your own hands to help gain control of HS. Here are some important strategies to try.

Steer Clear of Triggers

Certain factors can trigger HS flares, so learning what they are and taking measures to avoid them is key. The following can make HS worse:

• Overheating and sweating

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• Skin-on-skin friction
• Smoking

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• Stress

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• Wearing tight clothing

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Besides avoiding triggers, making these lifestyle changes may also help prevent and ease HS symptoms:

• Reach and maintain a healthy weight.

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• Quit smoking to reduce HS flares and prevent HS from worsening.

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• Get good-quality sleep. HS symptoms can disrupt sleep, which is vital to managing HS. Try to avoid a cycle of poor sleep and worsening HS symptoms.

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• Eat a healthy diet. In particular, Fernandez recommends an anti-inflammatory diet, which has been shown to reduce the risk of a number of chronic inflammatory diseases.

Practice Good Hygiene

A common myth about HS is that it’s caused by “not being clean,” Sokumbi says. Although that’s not true, some personal hygiene measures may help keep symptoms under control. Dr. Obioha recommends using antibacterial washes that contain chlorhexidine and benzoyl peroxide, as well as exfoliating cleansers with salicylic acid.

Wear Loose Clothing

Use Absorbent Pads and Foam Dressings

Absorbent patches, gauze, and foam dressings can help soak up sweat and discharge from weepy lesions. Fernandez recommends flexible dressings that will conform to areas such as the armpit without creating friction. Change dressings regularly, so the area doesn’t become moist.

Apply a Warm Compress

Change Up Your Shaving Routine

If possible, don’t shave areas prone to HS, to help prevent ingrown hairs, recommends Sokumbi. Another option is laser hair removal, which eliminates the actual follicles. “Follicular occlusion is at the heart of HS, so if you can get rid of the hair follicles early on, that’s something to consider,” she explains.

Get Support

If you’re having trouble finding a dermatologist experienced in treating Black people’s skin or would like to connect with others who are dealing with HS, visit the Hidradenitis Suppurativa Foundation. “It’s a patient advocate group with the goal of educating, supporting, and providing resources to HS patients,” says Fernandez. Having HS can be isolating, but you don’t have to go it alone.

• Hidradenitis suppurativa disproportionately affects Black individuals, and Black patients often experience more delays in diagnosis and have a harder time getting access to care.
• With medical treatments and self-care, managing HS for improved quality of life is possible.
• Finding a dermatologist who understands the unique needs of Black skin and actively seeking out resources for support are ways you can advocate for yourself.