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 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 Prognosis Chronic disease with recurrence Prognostic variable negative obesity smoking