Acne inversa

and Martina Feichter, medical editor and biologist

Sophie Matzik is a freelance writer for the medical team.

More about the experts

Martina Feichter studied biology with an elective subject pharmacy in Innsbruck and also immersed herself in the world of medicinal plants. From there it was not far to other medical topics that still captivate her to this day. She trained as a journalist at the Axel Springer Academy in Hamburg and has been working for since 2007 - first as an editor and since 2012 as a freelance writer.

More about the experts All content is checked by medical journalists.

Acne inversa (Acne inversa) is a skin disease in which extensive inflammation occurs, especially in the armpit and genital area. They are accompanied by accumulations of pus and severe pain. If left untreated, acne can inversely become chronic and significantly reduce the quality of life of those affected. Here you can read everything you need to know about the causes and symptoms of acne inversa, therapy and prognosis.

ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. L70

What is acne inversa?

Acne inversa (Acne inversa) is an inflammatory skin condition that primarily affects the areas where skin folds easily form. These are, for example, the armpits and the genital region. This leads to extensive inflammation, accumulations of pus, abscesses and noticeable scars. In addition, connecting ducts from the skin to other organs (fistulas) can form. If left untreated, acne inversa spreads more and more and takes a chronic course. Ultimately, the entire skin and subcutaneous fatty tissue of the affected regions can be affected.

Little is known about the serious illness to this day, as very few people suffer from it. Women are more likely to develop acne inversa than men. In most cases, the disease appears for the first time after puberty and before the age of 30.

By the way: In many cases, acne inversa occurs together with the more well-known acne vulgaris.

Acne inversa: symptoms

In the case of acne inversa, initially only the hair roots and the associated sebum and sweat glands become inflamed on the affected skin areas. Palpable lumps and swellings form that look like enlarged blackheads. The inflammation-related backlog of sebum and sweat secretions can over time lead to the formation of accumulations of pus (abscesses) in the area of ​​the sweat glands. The glandular tissue is destroyed. Branched ducts can form into deeper tissue layers or to the surface of the body (fistulas). The accumulations of pus can spontaneously empty and release pus, sebum or a bad-smelling secretion. After a few years, the affected regions are usually characterized by a large number of scars from previous foci of inflammation.

The following body regions are affected by these pathological processes of acne inversa:

• Armpits
• Afford
• Genital region
• Belly folds
• Wrinkles under the female breast

Acne inversa: effects and consequences

Because of the physical symptoms, acne inversa patients are severely impaired in their quality of life. In addition, the disease can have other effects that negatively affect the everyday, professional and relationship life of those affected. This includes:

• pains
• sleep disorders
• Restrictions on movement
• Obesity
• Disgust
• Disfigurement problems combined with a feeling of shame
• Sensation of wetness, soiling of clothes (when pus evacuated)
• Soft tissue swelling under the skin due to a disorder in the lymphatic system (lymphedema)
• limited performance
• Impairment of sex life
• Fear of secondary diseases: anemia, development of tumors in the area of ​​the anus and genitals
• Fear of stress in the family / in the social environment
• Fear of unemployment / financial problems
• Fear of genetic stress / heredity

Acne inversa: causes and risk factors

The exact causes of acne inversa are still unknown. However, experts suspect that disorders of the immune system and hormonal influences could play a role in the development of the serious skin disease. In addition, some people seem to have a hereditary predisposition to acne inversa.

What is certain is that certain factors can trigger or exacerbate the skin disease. These trigger factors include:

• Smoking (very important trigger factor for acne inversa!)
• severe overweight (obesity)
• Stress and mental stress
• sweat
• mechanical irritation (e.g. from tight clothing)
• Body hair removal (shaving)
• bacterial colonization of the hair follicles (especially with Staphylococcus aureus)

In addition, there is often a connection between acne inversa and some other diseases, such as the inflammatory bowel diseases ulcerative colitis and Crohn's disease.

Acne inversa: examinations and diagnosis

It often takes years before acne inversa is diagnosed. This is due, for example, to the fact that many sufferers go to the doctor late out of a feeling of shame. In addition, the disease is so rare that many medical professionals have little experience with it and therefore do not make the correct diagnosis straight away.

To clarify the skin changes, the doctor will first collect the patient's medical history (anamnesis) in a conversation. To do this, he has all symptoms and complaints described in detail and asks how long they have existed. He also asks about important risk factors for acne inversa, for example whether other family members have the skin disease and whether the patient smokes. The doctor will also measure the patient's weight and height to determine their body mass index (BMI). In addition to tobacco consumption, being very overweight is another important trigger factor for acne inversa.

This is followed by a physical exam. For example, the doctor carefully examines the skin changes and palpates the tissue. He can examine any fistulas more closely with the help of a probe. The doctor usually also takes blood samples to determine inflammatory parameters such as blood sedimentation and C-reactive protein.

Smears from the skin surface and samples from deeper tissue layers on the pathologically altered skin areas can also be informative. The germs present in it can be detected in the laboratory.

With the help of imaging procedures, the doctor can determine the depth of the disease or the fistula. Ultrasound examinations and magnetic resonance imaging (magnetic resonance imaging, MRI) are used.

Note: During his examinations, the doctor must rule out other diseases with similar symptoms such as acne inversa. These include, for example, a recurrent hair follicle inflammation (folliculitis), the deep, purulent inflammation of a single hair follicle (furuncle) or several neighboring hair follicles (carbuncle) and skin tuberculosis.

Acne inversa: treatment

Treating acne inversa is difficult and depends on the stage (severity) of the disease. Sometimes medication can relieve the symptoms and give the patient symptom-free or at least symptom-free phases. Often, however, surgical interventions cannot be avoided. In general, the acne inversa treatment takes place in medical centers that specialize in skin diseases. In Germany, this includes all major dermatological clinics and plastic surgery centers.

Drugs for acne inversa

For local wound treatment, antiseptic (antimicrobial) preparations are used, for example in the form of solutions or ointments (e.g. with polyhexanide, octenidine or PVP-iodine).

In addition, the doctor often prescribes antibiotics to get bacterial infections under control, which can significantly influence the course of acne inversa. The choice of active ingredients depends on the germs that are detected in the smears and tissue samples. For example, clindamycin, rifampicin and tetracyclines are available. They are applied topically or taken in tablet form.

More severe cases of acne inversa are sometimes treated with the so-called TNF inhibitor adalimumab (TNF = tumor necrosis factor). It is a biotechnologically produced monoclonal antibody that can slow down inflammatory processes in the immune system. It is therefore used, for example, for rheumatoid arthritis, psoriasis, Crohn's disease, ulcerative colitis and other autoimmune diseases.

Antiandrogens are occasionally prescribed to women with acne inversa. They have an inhibitory effect on the male sex hormones, which are also produced in small quantities in the female body. This can have a positive effect on the course of the disease.

Other drugs, such as corticosteroids ("cortisone") or acitretin, are used less often in the treatment of acne inversa.

Surgical treatment

In many cases, acne inversa also requires surgery. The doctor often has to open up foci of inflammation: the boils (abscesses) are cut open, emptied and rinsed with antibiotics.

Advanced acne inversa can usually only be cured in the long term by surgically removing diseased areas of the skin. Depending on the size of the defect and any existing wound healing disorders, there are three possible wound treatment options:

1. Secondary healing: Here the edges of the wound are sewn together and a scar is formed at the interface. Secondary healing is particularly suitable for smaller skin areas.
2. Near flap: In a near flap, healthy skin is moved away from the area in order to close the wound. The surgeon must ensure that the tension that develops in the skin does not restrict mobility.
3. Split skin grafting: With split skin grafting, healthy skin is removed from the back of the head or the thigh, for example, and placed in the wound. The area from which the skin was removed heals on its own like a scrape.

Other therapeutic measures

Laser therapies are (still) rarely used for acne inversa, for example to remove diseased tissue or as radiation therapy.

Regardless of the way in which acne inversa is treated - the success of the therapy also depends on whether it is possible to avoid trigger factors. Above all, patients should not smoke and should avoid or lose excess weight.

Acne inversa: prognosis

If left untreated, acne inversa can develop into a chronic condition that is associated with severe pain and a significant impairment of the quality of life. Many of those affected withdraw from social life, and some even develop depression. It is therefore very important to have an experienced dermatologist examine and treat you at an early stage if you suspect acne inversa.

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