Hidradenitis Suppurativa (HS) is a chronic inflammatory skin condition that causes painful, deep-seated lesions beneath the skin’s surface. It is often mistaken for severe acne or recurrent boils, leading to delays in diagnosis and treatment. This article explores the biology of HS, examines its typical locations, and clarifies the rare circumstances under which it might manifest on the face.
Understanding Hidradenitis Suppurativa
HS is primarily characterized as a disorder of the hair follicle unit, where a blockage occurs deep within the follicle. This occlusion is followed by a rupture of the follicle wall, spilling contents into the surrounding dermis. The immune system responds to this material as foreign, initiating the inflammatory response that is the hallmark of the disease.
This process results in the formation of firm, painful nodules that can progress into abscesses filled with fluid and pus. Repeated cycles of inflammation and healing lead to the creation of epithelial-lined tunnels, known as sinus tracts, which connect the lesions. HS is not caused by poor hygiene, although bacteria can colonize the lesions secondarily.
Typical Body Areas Affected
The characteristic lesions of HS are overwhelmingly found in specific areas rich in hair follicles and apocrine glands. These locations are often described as intertriginous areas, where skin surfaces rub against each other, creating friction. Friction is a contributing factor that exacerbates the disease process.
The concentration of apocrine sweat glands was once thought to be the direct cause of HS, but current understanding focuses more on the hair follicle itself. Common sites of involvement include:
- The armpits (axillae)
- The groin and inner thighs
- The skin beneath the breasts (inframammary folds)
- The buttocks, and the perianal or perineal regions
Why Facial HS Is Atypical
HS lesions rarely appear on the face, making a facial presentation atypical. This geographical difference lies in the varying types of glands present. The face is abundant in sebaceous glands and eccrine sweat glands, which are the main component of common acne.
True involvement of the face, such as the cheeks or forehead, is exceptionally rare. These sites lack the dense concentration of apocrine glands and the friction of intertriginous skin folds that characterize typical HS locations. HS has been documented infrequently on the scalp line, behind the ears (postauricular), and the neck.
When lesions resembling HS occur on the face, they may be a manifestation of a related disorder, such as severe cystic acne or acne conglobata. Facial HS tends to be associated with more severe, widespread disease and may be seen more frequently in men than women. These uncommon facial lesions can be difficult to recognize, often leading to misdiagnosis as common acne or cysts due to the unusual location. A clinical feature that may distinguish HS-related facial lesions is the development of rope-like or cribriform (sieve-like) scarring as the lesions heal.
Seeking Diagnosis and Management
If you notice painful, deep-seated lumps that recur in the same location, on your face or elsewhere, consult a dermatologist for an accurate evaluation. HS is a clinical diagnosis, meaning a healthcare provider determines the condition based on the appearance of the lesions, their location, and a history of recurrence. Self-diagnosing is difficult because HS can mimic other skin conditions, such as boils, folliculitis, or severe acne.
Early intervention is important to manage inflammation and prevent the long-term consequences of the disease, particularly scarring. While HS is chronic, a dermatologist can create a management plan to reduce the frequency of flares and the severity of symptoms. Do not delay seeking professional medical advice.