Snapshot A 35-year-old man presents to his dermatologist for further management of his skin disease. He has multiple abscesses arranged in a honeycomb pattern and draining serous fluid in his bilateral axilla. He has significant scarring in his inguinal area as well. He has tried several weeks of antibiotics and several courses of immunosuppressants with minimal effect. Due to the extensive scarring and non-responsiveness to medical management, he is referred for surgical debridement. Introduction Clinical definition chronic disease of occluded aprocrine glands and hair follicles characterized by painful cutaneous draining lesions, abscesses, and pilonidal sinuses this disorder does not respond well to antibiotics Epidemiology Incidence 1-4% worldwide Demographics 3:1 female to male ratio onset in 11-50 years of age rarely persists after menopause Risk factors positive family history smoking obesity mechanical friction (wearing tight clothes) medications lithium medroxyprogesterone acetate sirolimus Etiology Plugged apocrine gland or hair follicle Pathogenesis exact mechanism is unknown but theories include hormonal overstimulation of ductal keratinocyte production login to view 2 more bullets drug-induced disease login to view 2 more bullets Presentation Symptoms painful lesions that drain recurrent lesions Physical exam tender nodules, pustules, or abscesses with purulent or serous drainage may coalesce into multiple draining sinuses forming a honeycombed pattern may have scars from prior lesions location most commonly occurs in axillary, inguinal, and anogenital regions Studies Labs bacterial culture to look for superinfection Diagnostic criteria 1 or more painful, deep-seated nodules or abscesses or draining sinuses poor response to antibiotics chronic and recurrent disease Differential Folliculitis Vasculitis Acne vulgaris Treatment Conservative weight loss and smoking cessation indication login to view 1 more bullet warm compresses indication login to view 1 more bullet Medical topical antibiotics indication login to view 1 more bullet drugs login to view 1 more bullet oral antibiotics indications login to view 2 more bullets drugs login to view 4 more bullets immunosuppressants indication login to view 1 more bullet drugs login to view 4 more bullets Operative surgical debridement of sinus tracts or abscesses indications login to view 1 more bullet Complications Scarring and fibrosis incidence treatment Poor quality of life and psychologic burden Secondary superinfection Prognosis Chronic disease with recurrence Prognostic variable negative obesity smoking