HIDRADENITIS SUPPURATIVA

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1 Print Close Window Note: Large images and tables on this page may necessitate printing in landscape mode. Copyright The McGraw-Hill Companies. All rights reserved. Fitzpatrick Color Atlas, 5e > Part I: Disorders Presenting in the Skin and Mucous Membranes > Section 1. Disorders of Sebaceous and Apocrine Glands > HIDRADENITIS SUPPURATIVA Hidradenitis suppurativa is a chronic, suppurative, often cicatricial disease of apocrine gland bearing skin in the axillae, the anogenital region, and rarely, the scalp (called cicatrizing perifolliculitis). May be associated with severe nodulocystic acne and pilonidal sinuses (termed follicular occlusion syndrome). Synonyms: Apocrinitis, hidradenitis axillaris, abscess of the apocrine sweat glands. Epidemiology AGE OF ONSET From puberty to climacteric. SEX Affects more females than males; estimated to be 4% of female population. Males more often have anogenital and females axillary involvement. RACE All races. HEREDITY Mother-daughter transmission has been observed repeatedly. Families give a history of nodulocystic acne and hidradenitis suppurativa occurring separately or together in blood relatives. Etiology and Pathogenesis Unknown. Predisposing factors: obesity, genetic predisposition to acne, apocrine duct obstruction, secondary bacterial infection. Pathogenesis The following sequence may be the mechanism of the development of the lesions: keratinous plugging of the apocrine duct and hair follicle dilatation of the apocrine duct and hair follicle inflammatory changes limited to a single apocrine gland bacterial growth in dilated duct ruptured duct/gland resulting in extension of inflammation/infection extension of suppuration/tissue destruction ulceration and fibrosis, sinus tract formation. History Symptoms: Intermittent pain and marked point tenderness related to abscess formation in axilla(e) and/or anogenital area. Physical Examination

2 Skin Lesions Initial lesion: very tender, red inflammatory nodule/abscess (Fig. 1-11) that may resolve or drain purulent/seropurulent material. The same lesion may appear repeatedly in the same location. Open comedones, and at times unique double comedones, are highly characteristic of the disease (Fig. 1-11) and may be present even when active nodules are absent. Eventually, sinus tracts may form lesions moderately to exquisitely tender. Pus drains from opening of abscess and sinus tracts (Fig. 1-12). Fibrosis, "bridge" scars, hypertrophic and keloidal scars, contractures. Rarely, lymphedema of the associated limb may develop. Figure 1-11 Hidradenitis suppurativa Many black comedones, some of which are paired, are a characteristic finding, associated with deep exquisitely painful abscesses and old scars in the axilla. Figure 1-12

3 Hidradenitis suppurativa Severe scarring on the buttocks, inflammatory painful nodules with fistulas and draining sinuses. When the patient sits down, pus will squirt from the sinus openings. Distribution Axillae, breasts, anogenital area, groin. Often bilateral in axillae and/or anogenital area; may extend over entire back, buttocks (Fig. 1-12), and scalp. Associated Findings Cystic acne, pilonidal sinus. Often obesity. Laboratory Examinations BACTERIOLOGY Various pathogens may secondarily colonize or "infect" lesions. These include S. aureus, streptococci, Escherichia coli, Proteus mirabilis, and Pseudomonas aeruginosa. DERMATOPATHOLOGY Early: keratin occlusion of apocrine duct and hair follicle, ductal/tubular dilatation, inflammatory changes limited to a single apocrine gland. Late: destruction of apocrine/eccrine/pilosebaceous apparatus, fibrosis, pseudoepitheliomatous hyperplasia in sinuses. Differential Diagnosis Painful papule, nodule, abscess in groin and axilla. Early: furuncle, carbuncle, lymphadenitis, ruptured inclusion cyst, cat-scratch disease. Late: lymphogranuloma venereum, donovanosis, scrofuloderma, actinomycosis, sinus tracts and fistulas associated with ulcerative colitis and regional enteritis.

4 Course and Prognosis The severity of the disease varies considerably. Many patients have only mild involvement with recurrent, selfhealing, tender red nodules and do not seek therapy. The disease usually undergoes a spontaneous remission with age (>35 years). In some individuals, the course can be relentlessly progressive, with marked morbidity related to chronic pain, draining sinuses, and scarring, with restricted mobility. Complications (rare): fistulas to urethra, bladder, and/or rectum; anemia, amyloidosis. Management Hidradenitis suppurativa is not simply an infection, and systemic antibiotics are only part of the treatment program. Combinations of (1) intralesional glucocorticoids, (2) surgery, (3) oral antibiotics, and (4) isotretinoin are used. Medical Management ACUTE PAINFUL LESIONS Nodule Intralesional triamcinolone (3 to 5 mg/ml). Abscess Intralesional triamcinolone (3 to 5 mg/ml) into the wall followed by incision and drainage of abscess fluid. CHRONIC LOW-GRADE DISEASE Oral antibiotics: erythromycin (250 to 500 mg qid), tetracycline (250 to 500 mg qid), or minocycline (100 mg bid) until lesions resolve; may take weeks. Intralesional triamcinolone (3 to 5 mg/ml) into early inflammatory lesions helpful in hastening resolution of individual lesions. PREDNISONE May be given concurrently if pain and inflammation are severe: 70 mg daily for 2 to 3 days, tapered over 14 days. ORAL ISOTRETINOIN Not useful in severe disease, but it appears to be useful in early disease and when combined with surgical excision of individual lesions. Surgical Management Incise and drain acute abscesses. Excise chronic recurrent, fibrotic nodules or sinus tracts. If one or two nodules can be pin-pointed with recurrent disease, they can be excised with a good result. With extensive, chronic disease, complete excision of axilla or involved anogenital area may be required. Excision should extend down to fascia and requires split skin grafting. Psychologic Management These patients need constant reassurance, as they become very depressed because of the nature of the illness, e.g., pain, soiling of clothing by draining pus, odor, and the site of occurrence (anogenital area). Therefore, every effort should be made to deal with the disease, using every modality possible. Copyright The McGraw-Hill Companies. All rights reserved. Privacy Notice. Any use is subject to the Terms of Use and Notice. Additional Credits and Copyright Information.

5 Privacy Notice. Any use is subject to the Terms of Use and Notice. Additional Credits and Copyright Information.