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pus from local skin bacteria, and extensive scarring. If the lesions are large and deep, channels may form between the abscesses (these are fistulae) and to the skin (these are sinuses). These lesions are located where apocrine glands are most numerous: around the groin, the axillae, and under the breasts. It occasionally occurs on the scalp. And for people who are prone to this disorder, it can develop in areas of frequent skin friction, like around the neck or the waistband of trousers. HS is surprisingly common, affecting between 0.5 and 4 percent of the population. It occurs in women more often than men by a ratio of about 4:1. It usually arises in late adolescence or early adulthood; it is rare in young children, and it seldom develops after age 40. Many people, including Vicki, have HS for many years before realizing it is not just a severe form of acne that affects the armpits and groin. PATHOPHYSIOLOGY OF HIDRADENITIS SUPPURATIVA When a condition accumulates a lot of names over its history, this often indicates that scientists have struggled to understand it. HS is an example; it has been recognized as a condition since 1839, and since then it has been called Velpeau's disease, Verneuil's disease, acne conglobate, acne inversa, Fox-den disease, pyoderma sinifica fistulans, and several other names, and we still don't have a full understanding of how it comes about. The causes of HS are unknown. It appears to be multifactorial, with genetic components (about one-third of patients report a family history), some dysregulation in the immune system response to bacteria in the skin microbiome, and there may also be a hormonal element: high estrogen levels appear to suppress outbreaks. In recent years, HS has been proposed as an autoimmune disease, but experts who study this carefully suggest it is an autoinflammatory L i s te n to T h e A B M P Po d c a s t a t a b m p.co m /p o d c a s t s o r w h e reve r yo u a cce s s yo u r favo r i te p o d c a s t s 69 condition, which has some different implications, especially for treatment options. Author's note: The distinction between autoimmune and autoinflammatory conditions is new to me, and I explore it in more detail in the video that accompanies this article. HS has some predictable comorbidities—other diseases that occur along with it—and these may give some hints about systemic patterns in inflammation. People with HS are more likely than others to have heart disease, type 2 diabetes, and metabolic syndrome. Joint pain and arthritis near the affected areas are common. Patients are especially vulnerable to Crohn's disease, psoriasis, and various inflammatory conditions of the spine. Being overweight appears to increase both the risk and severity of this condition, and smoking has also been seen to make it worse. SIGNS AND SYMPTOMS HS lesions start with redness and pain. As the cysts grow, which can take place over just a few hours, they may fill with blood, pus, or other tissue exudate. The skin over the top of these abscesses may become stretched and tight. Older lesions may look like discolored bumps or nodules. HS cysts cause significant scarring, which can be deep and extensive enough to limit normal range of motion, especially at the axilla. The diagnostic criteria for HS include the appearance of the typical lesions: nodules, abscesses, sinus tracts, and scarring. These must appear at the axillae, the groin, or under the breasts. HS is also identified by the fact that these lesions frequently recur, with at least two episodes within six months. The severity of HS is sometimes ranked as Hurley Stages (named for the researcher who defined them). Hurley stage 1 involves solitary or multiple lesions, isolated abscesses, but no scarring or sinus tracts. Because this condition is often undiagnosed, and people can feel ashamed and self-conscious about it, many people with HS may simply avoid massage or try to explain their lesions in a way that doesn't feel embarrassing.