Hidradenitis suppurativa (HS), also known as acne inversa, is a chronic, inflammatory skin condition characterized by recurrent, painful lumps and deep-seated nodules that form beneath the skin’s surface. It is considered an autoinflammatory condition involving the hair follicles, not simply a bacterial infection or a result of poor hygiene. HS requires long-term management to control symptoms and prevent permanent tissue damage.
Understanding Hidradenitis Suppurativa
Hidradenitis suppurativa typically affects areas where skin folds meet or where there is a high concentration of apocrine sweat glands, such as the armpits (axillae), groin, inner thighs, buttocks, and beneath the breasts. The condition begins when a hair follicle blocks and ruptures, leading to an inflammatory immune response deep within the skin layer.
The lesions present as painful, deep nodules and abscesses that can persist for weeks or months. Recurring inflammation can lead to the formation of sinus tracts—small, tunnel-like connections under the skin that often discharge pus. This chronic process results in characteristic rope-like scarring and fibrosis, which can limit movement and cause disfigurement in the affected regions. HS is an inflammatory disease with an estimated prevalence of about 1% to 4% of the population, typically developing after puberty.
Atypical Presentation: HS Involvement on the Face and Scalp
While HS primarily affects skin folds, involvement on the face and scalp is possible, though uncommon. This is considered an atypical presentation because the face lacks the dense concentration of apocrine glands found in classic locations like the armpits or groin. Lesions on the head often involve the cheeks, jawlines, neck, and the occipital region of the scalp.
Facial HS is sometimes linked to more widespread disease or is part of the follicular occlusion tetrad. This tetrad involves HS alongside severe acne conglobata, dissecting cellulitis of the scalp, and pilonidal cysts. The lesions in these areas are still characterized by deep, painful nodules and abscesses.
The occurrence of HS on the head and neck suggests the primary issue is the inflammatory disorder of the hair follicle itself, rather than a strict reliance on apocrine glands. Diagnosing HS in these non-traditional sites can be challenging, as the presentation may be mistaken for other common facial skin issues. Recognizing the deep-seated, recurrent nature of the lesions is the first clue to an accurate diagnosis.
Distinguishing Facial HS from Common Skin Mimics
Facial HS is frequently misdiagnosed because its early symptoms closely resemble those of more common skin conditions, particularly severe acne (acne vulgaris). Both disorders involve inflammation of the hair follicle, resulting in similar-looking bumps and nodules. However, key features help distinguish HS from typical acne, boils, or simple cysts.
Unlike common acne, which is characterized by blackheads and whiteheads, HS lesions on the face are deep, intensely painful, and recurrent in the same spot. A crucial differentiator is the eventual development of sinus tracts—tunnels beneath the skin that connect the inflammatory bumps. These tracts and the subsequent formation of rope-like scarring are hallmarks of HS generally absent in routine acne.
Boils (furuncles) or typical cysts are usually isolated events caused by a localized bacterial infection that resolve after drainage. In contrast, HS is a chronic, systemic inflammatory disease; its lesions are persistent, often multiple, and less responsive to simple antibiotic or drainage procedures. The deep, interconnected nature of the lesions indicates that the underlying process is HS, not a superficial infection.
Targeted Management of Facial and Head Lesions
Treating HS on the face and head requires a tailored approach that balances aggressive disease control with the sensitivity and cosmetic considerations of the area. For milder, localized facial lesions, topical therapies are often the first line of treatment. A topical antibiotic like clindamycin, applied directly, can help reduce inflammation and prevent secondary infection.
Injections of corticosteroids directly into an inflamed nodule can quickly reduce pain and swelling, which is beneficial for isolated, early-stage lesions. For more widespread or moderate facial involvement, systemic treatments become necessary. These may include long-term courses of oral antibiotics, used for their anti-inflammatory effects, or oral retinoids.
For severe or unresponsive facial HS, systemic biologic medications that target specific inflammatory pathways are often prescribed. Gentle procedural options, such as laser hair removal, can also be beneficial because they reduce hair follicles and subsequent irritation that can trigger flares. Surgical interventions, like deroofing (removing the roof of a sinus tract), may be used for localized, persistent tunnels to minimize scarring and prevent recurrence.