Skin & Soft Tissue: Hidradenitis Suppurativa

Hidradenitis Suppurativa

Pathophysiology

  • Cause: Recurrent Follicular Occlusion
    • Involves the Follicular Portion of Folliculopilosebaceous Units (FPSUs)
    • *Historically Believed to be From Apocrine Sweat Gland Occlusion Although Now Opposed
  • Most Common Organisms: Staphylococcus & Streptococcus

Presentation

  • Most Common Sites:
    • Axilla
    • Groin
    • Perineum
    • Perianal
    • Inframammary
  • Presentations:
    • Recurrent Abscess
    • Inflammatory Nodules
    • Multiple Comedones
    • Sinus Tracts
    • Severe Scarring

Risk Factors

  • Women
  • Down Syndrome
  • Black Race
  • Obesity
  • Smoking
  • Excessive Deodorant Use

Hurley Stages

  • Stage I: Abscess, No Sinus Tracts or Scarring (68% – Most Common)
  • Stage II: Abscess with Sinus Tracts and Scarring, Separated by Normal Skin (28%)
  • Stage III: Diffuse Disease or Multiple Interconnected Tracts Across an Entire Area (4%)

Diagnosis

  • Clinical Diagnosis Base on History & Examination

Hurley Stage I 1

Hurley Stage II 1

Hurley Stage III

Treatment

Primary Treatments

  • Hygiene #1 (Do Not Shave or Use Deodorant)
  • Loose Clothing
  • Smoking Cessation
  • Weight Loss
  • Warm Compress

Acute Lesions

  • Abscess with Severe Pain: Incision & Drainage
    • *Generally Try to Avoid I&D Unless Absolutely Necessary Due to Increased Risk of Recurrence
  • If I&D Can Be Avoided: Intralesional Corticosteroids or Punch Debridement

Chronic Therapy

  • Stage I: Topical Clindamycin
    • If Fails: Oral Tetracycline (Doxycycline)
    • May Also Consider Antiandrogens (Oral Contraceptives or Spironolactone)
  • Stage II/III: Oral Tetracycline (Doxycycline) or Combination Oral Clindamycin & Rifampin
    • May Also Consider Antiandrogens (Oral Contraceptives or Spironolactone)
    • Options if Fails:
      • TNF-α Inhibitors (Adalimumab or Infliximab)
      • Oral Retinoids
      • Oral Dapsone
    • Severe Refractory Disease: Wide Excision
      • Leave Open or Graft/Flap; Do Not Close Primarily

References

  1. Piccolo D, Di Marcantonio D, Crisman G, Cannarozzo G, Sannino M, Chiricozzi A, Chimenti S. Unconventional use of intense pulsed light. Biomed Res Int. 2014;2014:618206. (License: CC BY-3.0)
  2. Alharbi Z, Kauczok J, Pallua N. A review of wide surgical excision of hidradenitis suppurativa. BMC Dermatol. 2012 Jun 26;12:9.(License: CC BY-2.0)