HIDRADENITIS SUPPURATIVA

DERMATOLOGY LECTURE NOTES

DEBABRATA BANDYOPADHYAY
PROFESSOR & HEAD, DEPT. OF DERMATOLOGY,
R. G. KAR MEDICAL COLLEGE, CALCUTTA, INDIA
 

 

Hidradenitis suppurativa (HS) is a chronic inflammatory disease resulting in suppurative, scarring lesions on apocrine gland-bearing areas such as axillae, groin, and perigenital regions. HS is often a disabling disease owing to chronically relapsing painful, discharging lesions.
 

  

ETIOLOGY

  • The cause is unknown. Predisposing factors include obesity and genetic factors, and hormonal influences (androgen excess or hyperresponsiveness).

  • The pathomechanism is somewhat similar to acne.

  • The primary event is occlusion of apocrine duct and pilosebaceous follicle leading to obstruction of outflow of secretion. Inflammatory changes in dilated apocrine duct and hair follicle takes place with secondary bacterial infections. Rupture of gland/duct results in spread of inflammation. Tissue destruction and suppuration leads to sinus formation and fibrosis.

CLINICAL FEATURES

  • Hidradenitis suppurativa begins after puberty.

  • Females are more commonly affected than males.

  • No racial predisposition.

  • The typical sites of affection are: axilla, groin, pubic region, perianal area, and buttocks. Bilateral lesions are common.

  • The initial lesions are painful and tender, indurated, subcutaneous, reddish nodules.

  • These lesions may subside or suppurate and burst to discharge serous or seropurulent material. Deep dermal involvement leads to indurated plaques.

  • Draining sinus tracts frequently develop.

  • Subsequent fibrosis lead to scars which are often band-like or hypertrophic and keloidal. Contracture of the area may develop.

  • Polyporous comedones (blackheads with two or more openings that communicate inside skin) are very characteristic.

  • HS may rarely be a part of the so called follicular occlusion triad (HS, acne conglobata, perifolliculitis capitis) or tetrad ( the triad plus pilonidal sinus).

  • Hidradenitis suppurativa may have considerable psychological impact with depression owing to chronic pain, malodorous discharge and soiling of clothing, and involvement of anogenital areas.

 

DIFFERENTIAL DIAGNOSIS

  • Carbuncle

  • Furunculosis

  • Lymphadenitis

  • Scroduloderma

  • Lymphogranuloma venereum

  • Donovanosis

  • Actinomycosis

  • Mycetoma

  • Sinus and fistula associated with inflammatory bowel disease

  • Ruptured inclusion cysts

  • Pilonidal sinus

 
 

DIAGNOSIS AND WORKUP

  
 

  • Typical clinical features of painful nodules, discharging sinuses, thick scars and double comedones over areas of predilections are fairly diagnostic.

  • Culture and sensitivity of discharge should be done. The organisms isolated may include Staph aureus, streptococci, bacteroides sp., E. coli, proteus, and pseudomonads.

  • Histopathologic features in early phases show keratin occlusion of apocrine and hair follicle and inflammatory changes. Late changes include destruction of appendages, pseudoepitheliomatous hyperplasia, and fibrosis in association with features of chronic inflammation.

 

  
 

COURSE AND PROGNOSIS

  
 
  • There is considerable variation in the severity and extent of the disease.
  • Some patients have recurrent painful nodules that subside without much complication.
  • Chronically relapsing and progressive course with many sinuses and severe fibrosis in some patients can be quite disabling.
  • Hidradenitis suppurativa tend to undergo spontaneous remission with age (fourth decade)
  • Chronic sequelae of hidradenitis suppurativa may include anemia, amyloidosis, arthropathy ,and rarely squamous cell carcinoma.
 
 

TREATMENT

  
 

  • Regular cleansing with antibacterial soaps.

  • Correction of obesity.

  • Antibacterials:
       Long-term systemic antibacterials are treatment of choice in chronic disease.. Tetracyline, doxycycline, minocyclne, and erythromycin are preferred. Alternatives include co-trimoxazole, and metronidazole.

          Topical antibacterials: clindamycin has been shown to give benefits.

  • Isotretinoin : orally, may be helpful in early disease in some patients.

  • Intralesional triamcinolone helps resolution of inflamed nodules in acute disease.
     

  • Systemic steroid may be employed as a concurrent  therapy  in severe inflammatory disease.
     

  • Surgical treatment:

               Incision and drainage of acute abscesses
               Excision of areas of repeated recurrences in localized disease.
               In widespread involvement, total excision of axilla or anogenital area
               followed by grafting may be required.

            

 
 

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