Stage 3 Hidradenitis Suppurativa (HS) and Tunneling

What is HS?

HS typically affects areas like the armpits, groin, buttocks, under the breasts, and the anogenital region. It can begin after puberty and often becomes chronic. Although it is more common in women, Stage 3 is generally more frequently seen in men.

The Hurley staging system classifies HS into three stages:

• Stage 1: Single or multiple painful nodules with no sinus tracts or scarring.

• Stage 2: Recurrent nodules with limited sinus tract formation and scarring.

• Stage 3: Extensive lesions with multiple interconnected sinus tracts and wide areas of scarring.

Stage 3 HS: Tunneling Beneath the Skin

In Stage 3 HS, sinus tracts form under the skin and gradually merge, creating a network of tunnels connecting inflamed areas. This process is referred to as tunneling.

What is Tunneling?

Tunneling refers to the creation of permanent sinus tracts beneath the skin due to chronic inflammation and infection. These tracts:

• Can continuously drain pus

• May open to the skin surface at multiple points

• Are interconnected and facilitate the spread of new abscesses

• Can destroy more skin tissue if left untreated

Signs of Tunneling

• Persistent, non-healing swellings

• Hard, painful lumps under the skin

• Multiple drainage points on the skin

• Foul-smelling discharge

• Thickened, hardened skin (scar tissue)

Why Does Tunneling Occur?

Main causes of tunneling include:

• Inadequate or delayed treatment

• Repeated infections

• Intense inflammation

• Smoking and obesity

• Genetic predisposition

Diagnosis and Imaging in Stage 3

Diagnosis is usually clinical, but to assess the extent of tunneling:

• Ultrasound

• MRI (Magnetic Resonance Imaging)
  can be used. MRI is especially helpful in visualizing the depth and connections of sinus tracts.

Treatment: Topical Creams Are Not Enough

In Stage 3 HS, topical treatments are usually insufficient. If tunneling is present, a combination approach is essential:

1. Medical Treatment

• Antibiotics: The most common regimen is rifampicin + clindamycin.

• Biologics: Especially adalimumab (anti-TNF agents) are effective in severe cases.

• Retinoids: May be used in selected cases.

• Zinc gluconate or hormonal therapies (especially for female patients) can be supportive.

2. Surgical Intervention

• Sinus excision: Surgical removal of tunnels.

• Wide excision: Complete removal of the affected area, sometimes followed by grafting.

3. Lifestyle Modifications

• Quitting smoking

• Weight control

• Wearing sweat-reducing clothing and maintaining hygiene

• Reducing stress

• Avoiding processed foods

• Eliminating dairy products (especially cheese containing casein)

Living with HS: Psychological Effects and Support

Depression, social isolation, and anxiety are common in Stage 3 HS patients. Therefore:

• Psychological counseling

• Patient support groups

• Online forums and patient associations are highly beneficial.

Conclusion

Hidradenitis Suppurativa, especially at Stage 3 with tunneling, can significantly reduce quality of life. However, with an accurate diagnosis, an effective treatment plan, surgical management, and proper patient education, the disease can be controlled.

HS leaves marks not only on the skin but also on a person’s life. Therefore, it should not be viewed as just a skin problem, but as a chronic and systemic disorder.