AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Background

Hidradenitis suppurativa is an annoying chronic condition characterized by swollen, painful, inflamed lesions in the axillae, groin, and other parts of the body that contain apocrine glands. The disease is a chronic acneiform infection of the cutaneous apocrine glands that also can involve adjacent subcutaneous tissue and fascia. The hallmark of the disease is sinus tracts (which can become draining fistulas) in the apocrine gland body areas. Velpeau first described the condition in 1839.

Pathophysiology

The condition has classically been thought to occur when apocrine gland outlets become blocked by perspiration or are unable to drain normally because of incomplete gland development. Secretions trapped in the glands force perspiration and bacteria into surrounding tissue, causing subcutaneous induration, inflammation, and infection. However, more recent studies have indicated that hidradenitis suppurativa is caused by follicular occlusion first, which, in turn, occludes the apocrine glands and causes perifolliculitis. Therefore, it is actually a disorder of the terminal follicular epithelium located in the apocrine gland-bearing skin areas, which may better be termed as acne inversa.

Hidradenitis suppurativa is confined to areas of the body that contain apocrine glands. These areas are the axillae, areola of the nipple, groin, perineum, circumanal, and periumbilical regions.

Often, patients with hidradenitis suppurativa also are afflicted with acne, pilonidal cysts, and chronic scalp folliculitis; thus, giving rise to the term follicular occlusion tetrad.

For further information, see Hidradenitis Suppurativa.

Frequency

United States

The problem is somewhat common, thought to occur in 1-2% of the population, but the precise incidence and prevalence are unknown.

International

A Danish study noted the prevalence of hidradenitis suppurativa to be in 4% of women.¹

Mortality/Morbidity

Hidradenitis suppurativa is painful and can be disabling but is rarely fatal, except when it progresses to overwhelming systemic infection in an immunocompromised patient. Extensive disease can prevent patients from performing normal work functions and from engaging in normal social activities. In some patients, especially those with severe disease, the condition creates significant psychological problems, particularly regarding sexual relationships.

Race

Ingrown hairs are a predisposing factor, thus an increased incidence of the disease occurs in patients with tightly curled hair.

Sex

The incidence of hidradenitis suppurativa is greater in females than in males, thought to be in the range of 4:1 or 5:1. Flare-ups have been associated with menses, with a higher incidence in females with shorter cycles and more days of bleeding during the period.

Age

Hidradenitis suppurativa does not present prior to puberty because the apocrine glands are inactive until triggered by a surge in sex hormones. The condition may be observed in patients of any age after puberty.

CLINICAL

Section 3 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

History

The most common presentation is that of painful, tender, firm, nodular lesions under the arms.

• The nodules may open and drain pus spontaneously. Nodules will heal slowly, with or without drainage, over 10-30 days.
• In typical cases, nodules recur at least several times yearly.
• In severe cases, the patient may suffer a constant succession of new lesions forming as soon as old lesions heal.
• Excessive heat, perspiration, tight clothing, and obesity seem to aggravate the condition. Studies also show that cigarette smoking is a precipitator of the condition.
• Remissions may last months or years.

Physical

• The patient may present in considerable pain, with multiple red, hard, raised nodules in areas where apocrine glands are concentrated.
• Affected areas may include the axillae, periareolar, intermammary zones, pubic area, infraumbilical midline, gluteal folds, genitofemoral areas (top of the thighs in genital area), and the perianal region.
• As suppuration progresses, surrounding cellulitis may be present. Chronic recurrences result in palpable thick sinus tracts under the skin, which may turn into draining fistulas.
• The patient may present with a chronic condition in which the multiple nodules have coalesced and are surrounded by a fibrous reaction. This results in scarred and unsightly appearance of the area.
• Hidradenitis suppurativa may resemble recurrent bacterial folliculitis and furunculosis.

Causes

• A genetic predisposition to hidradenitis suppurativa likely exists, with one study noting that 38% of patients had a relative with hidradenitis.
• Excessive perspiration, often observed in athletes and the obese, may contribute to clogging of the apocrine glands.
• Disease activity may be related to stress and to cigarette smoking.
• Hidradenitis may be observed as a primary condition without any obvious cause, but it may be observed in association with the following conditions:
• • Crohn disease
  • Irritable bowel syndrome
  • Down syndrome
  • Certain forms of arthritis
  • Graves disease or Hashimoto thyroiditis
  • Sjögren syndrome
  • Herpes simplex

DIFFERENTIALS

Section 4 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Other Problems to be Considered

Bacterial folliculitis and furunculosis
Granuloma inguinale
Lymphogranuloma venereum
Pilonidal cysts
Tuberculous inflammation of the skin
Carbuncle
Epidermoid or dermoid cyst

WORKUP

Section 5 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Lab Studies

• Culture of any exudate obtained (if aspiration or drainage of larger nodules is necessary) will yield a variety of saprophytic and pathogenic bacteria with a preponderance of staphylococci and streptococci.
• Thyroid function studies may be useful if clinically indicated because an association with Graves disease or Hashimoto thyroiditis may occasionally occur.
• If a patient appears toxic or is febrile, laboratory tests should include the following:
• • CBC
  • Blood cultures
  • Culture of exudate
  • Routine chemistries

Procedures

• Incision and drainage may be helpful for large, painful, fluctuant nodules that have not opened spontaneously.
• Most nodules will resolve even without drainage.

TREATMENT

Section 6 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Emergency Department Care

• The nodules of hidradenitis suppurativa may need to be drained in the emergency department, particularly if they are very large, fluctuant, and painful.
• Antibiotics are indicated if cellulitis or fever is present, and the patient should be admitted if he or she appears to be toxic.

Consultations

• General surgery
• • Surgical consultation may be obtained for removal of sinus tracts, curettage, and exteriorization of the gland.
  • Excision and skin grafting may be helpful for severe intractable cases. Also, surgery should be considered in early cases because the area to excise is smaller and less damaged from recurrences.
  • The CO₂ laser has been used to strip away glandular tissue. Healing is by secondary intention.
• Radiation treatment has also been used for this condition.

MEDICATION

Section 7 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Tetracycline and erythromycin may be helpful on a long-term basis, and cephalosporins often will help in acute cellulitis. On a short-term basis in the emergency department, dicloxacillin is considered a good choice. However, consideration must be given to using a sulfonamide or clindamycin antibiotic because of the growing presence of methicillin-resistant Staphylococcus aureus (MRSA) for both short-term and long-term treatment. Topical products, such as benzoyl peroxide, may be helpful. Topical and intralesional injections of corticosteroids are sometimes helpful.

Topical clindamycin cream has also been used with some success. Retin-A has rarely been found to be helpful in some patients. Systemic retinoids (Accutane) can reduce the severity of attacks in some patients but is not a reliable cure for hidradenitis suppurativa. Accutane cannot be prescribed in the emergency department due to requirements set forth by the pharmaceutical company. Hormonal manipulation (eg, certain oral contraceptives) has been useful for some patients but is unlikely to be prescribed from the emergency department.

Drug Category: Antibiotics

Therapy must cover all likely pathogens in the context of the clinical setting. In recurrent disease, antibiotics may be administered for 2 or more months.

Drug Category: Retinoids

These agents inhibit sebaceous gland function and keratinization.

Drug Category: Corticosteroids

These agents modify the body's immune response to a variety of stimuli. Intralesional injections have been used in addition to the cream.

FOLLOW-UP

Section 8 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Further Inpatient Care

• In severe cases, radical excision of the pathologic tissue with split-thickness skin grafts may be indicated.
• Radiation and laser treatments may be considered as well. However, the reason to admit a patient from the emergency department with hidradenitis suppurativa would be due to toxicity or sepsis, so the main treatment would be supportive antibiotics, such as intravenous clindamycin, vancomycin, and piperacillin and tazobactam sodium (Zosyn).

Deterrence/Prevention

• Minimize heat exposure and sweating.
• Lose weight if overweight.
• Avoid constrictive clothing and frictional trauma.
• Avoid underarm antiperspirants and deodorants (this has not been proven to make a difference).

Complications

• Lymphedema due to lymphatic injury from inflammation and scarring
• Contracture formation at the sites of lesions
• Squamous cell carcinoma (may develop in indolent sinus tracts)
• Disseminated infection (rare)
• Restricted limb mobility from scarring
• Urethral/rectal fistula
• Anemia secondary to chronic infection
• Arthritis secondary to inflammatory injury

Prognosis

• Individual lesions usually heal slowly in 10-30 days with or without drainage.
• Recurrences are common.
• Spontaneous complete resolution occurs in rare cases.
• Relentlessly progressive scarring and sinus tracts may occur.

REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

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21. von der Werth JM, Williams HC. The natural history of hidradenitis suppurativa. J Eur Acad Dermatol Venereol. Sep 2000;14(5):389-92. [Medline].
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Article Last Updated: Mar 28, 2008