Is hidradenitis suppurativa (HS) a lifelong condition?

Hidradenitis Suppurativa Is a Chronic, Lifelong Condition

Yes, hidradenitis suppurativa (HS) is a chronic, lifelong condition that requires ongoing management. According to the British Association of Dermatologists guidelines, HS is explicitly defined as a "chronic, inflammatory, recurrent, debilitating, skin follicular disease" 1. While treatments can control symptoms and induce periods of remission, the underlying condition persists throughout life.

Understanding the Nature of HS

HS is characterized by:

• Chronicity: The diagnostic criteria specifically require that the disease must be "chronic and recurrent" 1
• Onset: Typically presents after puberty, with peak onset in the second to fourth decades of life 1
• Pathology: Primarily a disease of follicular occlusion with significant inflammatory response 1
• Prevalence: Affects approximately 0.1% to 1% of the population, with higher rates among certain demographics 1

Key Features That Establish HS as a Lifelong Condition

1. Disease Definition and Progression

HS is defined by its chronic, recurrent nature. The disease typically follows a pattern of:

• Painful deep-seated nodules and abscesses
• Progression to sinus tracts and scarring in untreated cases
• Long-standing disease resulting in fibrosis, dermal contractures, and reduced mobility 1

2. Management Approach

The management pathway outlined in guidelines demonstrates the chronic nature of HS:

• Initial treatments focus on controlling symptoms
• Ongoing assessment of response at regular intervals
• Escalation of therapy for inadequate response
• Consideration of treatment breaks to assess ongoing need for therapy 1

This stepped approach acknowledges that HS requires continuous monitoring and management throughout life.

3. Comorbidity Profile

HS is associated with numerous chronic conditions that further emphasize its lifelong nature:

• Cardiovascular disease (nearly doubled risk of cardiovascular-associated death) 1
• Depression and anxiety (prevalence as high as 30%) 1
• Inflammatory bowel disease (particularly Crohn's disease) 1
• Metabolic syndrome 2

Management Implications of HS as a Lifelong Condition

Understanding that HS is a lifelong condition has important implications for management:

1. Early Intervention: Critical to prevent irreversible skin damage and tunnel formation 2

2. Long-term Treatment Planning:

   • Medical therapies (antibiotics, biologics) for inflammatory phase
   • Surgical interventions for destructive phase
   • Combined approaches often needed 2

3. Monitoring for Comorbidities: Regular screening for associated conditions is essential 1

4. Quality of Life Focus: Management should address pain, psychological impact, and functional limitations 3

Common Pitfalls in HS Management

1. Delayed Diagnosis: Average diagnostic delay is 7-10 years, leading to disease progression and complications

2. Inadequate Treatment: Treating only acute flares without addressing the chronic nature of the disease

3. Overlooking Comorbidities: Failing to screen for and manage associated conditions

4. Focusing Only on Skin Manifestations: Not addressing pain, psychological impact, and quality of life issues

5. Unrealistic Expectations: Promising "cure" rather than managing expectations about lifelong management

Conclusion

While treatments can effectively control symptoms and induce periods of remission, the underlying pathophysiology of HS persists. The disease definition, management approach, and associated comorbidities all support that HS is a chronic, lifelong condition requiring ongoing care and monitoring. Early diagnosis and comprehensive management are essential to minimize disease progression and improve quality of life.