Hidradenitis suppurativa

"Suppurativa" redirects here. For acrodermatitis continua suppurativa, see Dermatitis repens.

Verneuil’s disease is a chronic inflammatory skin condition primarily affecting areas rich in hair follicles (axillae, groin, anogenital, and inframammary regions). The disease is painful, disabling, and potentially life-threatening due to complications such as septicemia, cardiovascular involvement, surgical complications, and metabolic comorbidities.^[5]

Hidradenitis suppurativa
Other names	Acne inversa, apocrine acne, Verneuil's disease, Velpeau's disease[1]
Hidradenitis suppurativa (Hurley's stage II) in the left armpit
Specialty	Dermatology
Symptoms	Multiple inflamed and swollen skin lesions[2]
Usual onset	Childhood and Young adulthood[2]
Duration	Long-term[2]
Types	Stage I, II, III[1]
Causes	Unknown[3]
Diagnostic method	Based on symptoms[2]
Differential diagnosis	Acne, acne conglobata, pilonidal cysts[2]
Treatment	Warm baths, laser therapy, surgery[2][4]
Medication	Secukinumab, antibiotics, immunosuppressive medication[2]
Frequency	1–4% of people, when mild cases are included[2][3]
Deaths	Rare[1]

Contrary to popular belief, it is not simply a succession of “abscesses,” but rather a chronic inflammation of follicles and associated glands that can cause deep and extensive lesions.^[6]

Prevalence is estimated between 0.5 and 1% of the general population.^[7] Diagnosis is often delayed, with an average lag of 7 years.^[8]

Studies suggest genetic, immunological, and endocrinological involvement (hormonal imbalance, hypercortisolism, metabolic syndrome).^[9]

Management

Management of Verneuil’s disease combines medical, surgical, and supportive approaches.

• **Medical treatments**:

 - Systemic antibiotics can reduce inflammation but do not induce remission.[10]  
 - Biologics, especially anti-TNFα agents (adalimumab), are an option for moderate to severe cases, with partial efficacy in reducing flares.[11]  
 - Non-steroidal anti-inflammatory drugs (NSAIDs) are not considered disease-modifying therapy.  

• **Surgery**:

 - The main surgical procedure is **wide excision** of the diseased area, removing inflamed and scarred tissues.  
 - This aims to limit local recurrences but may require multiple interventions over a patient’s lifetime.[12]

• **Palliative care**:

 - Complete cure of Verneuil’s disease is currently not possible.  
 - **Palliative care should be a key indication** in severe and chronic forms, including pain control, psychological support, and social assistance.[13]  
 - This approach is essential to improve patients’ quality of life.  

• **Endocrinological assessment**:

 - Several studies suggest involvement of metabolic and hormonal abnormalities, particularly regarding **cortisol** and insulin resistance.[14]  
 - A **systematic endocrinological workup** is recommended to detect comorbidities (diabetes, metabolic syndrome), frequently associated with severe forms.  

• **Radiotherapy**:

 - In selected refractory cases, low-dose irradiation has been reported to improve resistant lesions, though indications remain limited to highly recurrent cases.[15]

Low-dose radiotherapy and adalimumab in Verneuil’s disease

Both low-dose radiotherapy and adalimumab (Humira) are therapeutic options studied in Verneuil’s disease (hidradenitis suppurativa, HS), particularly in patients refractory to conventional treatment or ineligible for surgery.

Low-dose radiotherapy

Radiotherapy targets skin lesions, reducing inflammation, follicular proliferation, and fibrosis. It contributes to regression of nodules and superficial fistulas, and reduces pain.

• Efficacy: 78.3% improvement in a German study (2000, n = 231)^[16] ; 72.5% improvement in a Swiss study (2021, n = 40)^[17]

• Side effects: mild skin burns (rare), theoretical long-term risk of carcinogenesis. Overall considered safe at low doses.

Adalimumab (Humira)

Adalimumab is a TNF-α inhibitor approved for moderate to severe HS. It reduces nodules and fistulas.

• Efficacy: about 54% of patients reached HiSCR at week 16 (SOLACE, 2021)^[18] ; 41.8% at week 12 (PIONEER I & II, 2016)^[19]

• Side effects: common mild infections, local injection reactions; rare severe infections and autoimmune disorders. Patient response is variable.

Comparison of treatments

Treatment	Approximate efficacy	Common side effects	Severe adverse events	Overall risk
Low-dose radiotherapy	72–78%	Mild skin burns (rare)	Cutaneous carcinogenesis (theoretical, very rare)	Low
Adalimumab (Humira)	42–54%	Mild infections, local reactions	Severe infections, allergic reactions, autoimmune disorders	Moderate to high

Dermal substitutes and artificial skin in surgical management of Verneuil’s disease

In advanced Verneuil’s disease (hidradenitis suppurativa, HS; Hurley II–III), surgery — particularly wide excision — is often necessary. This approach can leave large skin defects, requiring innovative reconstructive techniques.

Acellular dermal substitutes (Matriderm®)

- A 33-year-old female with refractory HS underwent axillary reconstruction with an acellular dermal substitute (*Matriderm®*) combined with immediate split-thickness skin grafting. This produced supple, durable skin with good healing, potentially limiting recurrence in the treated area.^[20]

Bilayer dermal regeneration template

- In a study of four patients, a two-step technique was used: wide excision followed by immediate application of a bilayer dermal regeneration template, then closure with a split-thickness graft. No recurrences were observed, though minor complications such as graft or template loss occurred.^[21]

Acellular dermal matrix + split-thickness skin graft as co-graft

- A novel reconstructive method using a co-graft of acellular dermal matrix and split-thickness graft was tested in two cases. It enabled rapid wound closure with good functional and aesthetic outcomes, assessed by laser analysis, cutometry, and quality of life measures.^[22]

Conclusion and perspectives

Acellular dermal substitutes and related techniques offer promising alternatives to conventional secondary healing after excision in severe HS. They may allow for more supple, durable, and aesthetic skin reconstruction, while potentially reducing local recurrences. However, data are **limited to very small series**; prospective comparative studies are required to confirm these results and define best surgical practices.

Pathophysiology

Verneuil’s disease is a chronic inflammatory disorder of the hair follicle. It begins with follicular obstruction, followed by local inflammation spreading to adjacent tissues, leading to nodules, sinus tracts, and scarring.^[23]

Contrary to earlier belief, it is not a primary infection of sweat glands, but rather a disorder of follicular occlusion (follicular rupture, secondary inflammatory reaction).^[24]

Immunological abnormalities (inappropriate activation of innate and adaptive immunity) and endocrinological factors (possible roles of cortisol and androgens) are also implicated.^[25]

A systematic endocrinological workup (cortisol, androgens, glucose metabolism) is recommended, given the documented links with diabetes and metabolic syndrome.^[26]

Staging and progression

Severity of Verneuil’s disease is classified by the Hurley staging system:

• **Stage I**: isolated inflammatory lesions, without sinus tracts.
• **Stage II**: recurrent inflammatory lesions with sinus tracts and scarring, affecting one or more anatomical sites.
• **Stage III**: diffuse or near-diffuse involvement, with multiple interconnected lesions, extensive sinus tracts, and massive scarring.^[27]

Progression is characterized by alternating active inflammatory phases and partial remissions. The disease is chronic and disabling, with severe forms causing major functional and social limitations.^[28]

Surgical treatment, when indicated, involves **complete excision of the affected area** to remove inflamed and fibrotic tissues. This is not simple drainage, but wide excision aimed at reducing local recurrences.^[29]

Complications and mortality

Verneuil’s disease leads to numerous physical, psychological, and social complications.

• **Physical complications**:

 - Formation of **scar contractures** causing functional limitations.  
 - Recurrent infections and chronic skin involvement.  
 - Increased risk of **cutaneous squamous cell carcinoma** in chronically inflamed areas.[30]

• **Pain and mental health**:

 - Severe chronic pain may be resistant to standard treatments and is a major risk factor for depression and suicidal ideation.[31]  
 - Several studies report high prevalence of **anxiety and depressive disorders**.  

• **Mortality and Hazard Ratio**:

 - A Danish cohort study showed HS patients had an **all-cause mortality Hazard Ratio of 2.48** compared with the general population.[32]  
 - By comparison:  
   - Crohn’s disease: HR ≈ **1.39**.[33]  
   - Breast cancer: specific mortality HR ≈ **1.5 – 2.0** depending on stage.[34]  
   - Localized prostate cancer: disease-specific mortality HR ≈ **1.4**.[35]

• **Conclusion**:

 - Verneuil’s disease is associated with **increased mortality**, comparable or superior to certain common cancers.  
 - These data support recognition of the disease as a **potentially life-threatening condition**, justifying better multidisciplinary management and systematic access to palliative care.

Comorbidities

Verneuil’s disease is frequently associated with:

• metabolic syndrome and type 2 diabetes;^[36]
• chronic inflammatory bowel diseases (notably Crohn’s disease);^[37]
• increased cardiovascular risk due to systemic inflammation and metabolic comorbidities.^[38]

Psychological and socio-economic impact

Quality of life is severely impaired (DLQI), with high prevalence of depression, anxiety, and suicidal ideation. The disease causes absenteeism, loss of income, and socio-economic vulnerability. Workplace adjustments and social support are essential.^[39][40]