Updated: 5/3/2019

Hidradenitis Suppurativa

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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
        • this leads to accumulation of keratinocytes, leading to occlusion (comedos)
        • ongoing occlusion and accumulation of material leads to increased innate immunity reaction, exacerbating accumulation of cellular debris and cyst formation
      • drug-induced disease
        • lithium may increase neutrophil migration and epithelial cell proliferation which occludes follicles
        • medroxyprogesterone acetate acts as an androgen, inducing hormonal stimulation of epithelial material production
  • Prognosis
    • chronic disease with recurrence
    • prognostic variable
      • negative
        • obesity
        • smoking
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
        • may help with reduction of recurrence
    • warm compresses
      • indication
        • to minimize symptoms
  • Medical
    • topical antibiotics
      • indication
        • for mild disease
      • drugs
        • topical clindamycin 1%
    • oral antibiotics
      • indications
        • for mild disease not responsive to topical therapy
        • for maintenance therapy between outbreaks
      • drugs
        • minocycline
        • doxycycline
        • amoxicillin-clavulanate
        • clindamycin
    • immunosuppressants
      • indication
        • for moderate or severe disease not responsive to antibiotics
      • drugs
        • adalimumab
        • infliximab
        • ustekinumab
        • cyclosporine
  • Operative
    • surgical debridement of sinus tracts or abscesses
      • indications
        • in patients refractory to all medical treatments
Complications
  • Scarring and fibrosis
    • incidence
    • treatment
  • Poor quality of life and psychologic burden
  • Secondary superinfection

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