A condition in which the armpit/groin sweat glands become blocked
and subsequently infected, leading to a spectrum of disease from
small local abscesses to extensive chronic inflammation and scarring
of complete skin areas in multiple sites.
Common - up to 1:300. Age
Not seen in the prepubuscent (before apocrine glands develop).
Peaks in third decade. Sex F3:1M.
More commonly perineal in men and axillary in women. Risk factors Personal
Poor hygeine may contribute
Strong association between smoking and perianal disease has been
Mechanical / Infection superimposed
Apocrine glands are deep lying sweat glands that typically drain
into a hair follicle.
- they secrete thick milky substances that become smelly with
bacterial action and are of unknown significance in humans.
Primary abnormality is probably occlusion of apocrine ducts by
Trapped secretions then act as a nutritive source for infection to
The gland may subsequently rupture into the dermis and subdermal
Infection (commonly Bacteroides) may then directly extend through
Natural history Affects any area with apocrine glands: axillae, groin, buttocks,
scrotum, perineum, submammary, areolar, and periumbilical.
A wide spectrum of severity ranges from acute single site disease to
chronic involvement of complete apocrine areas in multiple sites.
In the chronic form, multiple, large interconnected deep-seated
abscesses develop, with sinus tracts between the lesions and
Complications Severe scarring may result from chronic disease.
SCC occasionally arises in such chronically scarred areas.
MANIFESTATIONS Symptoms Local
Deep seated swollen nodules may be noted first.
Become red, painful and hot as infection develops.
If chronic, persistant painful unsightly coalesced lesions develop,
with chronic scarring and swelling.
May discharge with multiple openings.
Weight reduction in the obese.
Antibiotics in short courses may be enough in early or mild disease
(eg metronidazole). Chronic low-dose antibiotics (eg erythromycin) may be curative
in chronic cases.
Retonoic acid has been variably proved effective, though has
significant side effects.
If not responsive to antibiotics.
Local incision and drainage, with oral antibiotics.
Provides relief, but disease often reoccurs.
Unroofing or excision of inflamed tracts.
With chronic local disease, limited local excision and direct
primary suture is possible.
When chronic and extensive disease occurs, treatment is difficult.
Radical surgery may be required, wide excision and grafting; usually
being more successful in the axilla than elsewhere.
Abscess without sinus or scarring manage with medical
Recurrent abscesses with sinus tract formation and
cicatrisation. Single or
multiple widely spaced lesions. Manage with drug therapy and
of recalcitrant lesions
Diffuse or near-diffuse involvement or multiple interconnected
How is it treated
For all patients: avoid tight synthetic
clothes, avoid hot humid
environments, weight reduction and smoking cessation. Use
Hurley Stage I: Topical Abx (Clindamycin)
triamcinolone. Systemic oral Abx for resistant cases.
(COCP with spirinolactone for women and dutasteride for men).
Hurley Stage II: Long-term oral Abx
(Rifampicin and Clindamycin). After
I&D use oral augemtin for 7 days and the maintenance
Stage III disease: Surgical intervention
with concurrent medical
therapy. Pre-operative prednisolone, cyclosporine or infliximab
clindamycin. Unroofing or deroofing of all cysts with healing by
intention or mesh SSG to aid healing.
What are the
I&D: Used for tense abscesses too
painful to bear. Wound deeply
incised under LA and wound packed. Lesions recur and there is no
Local or extensive unroofing: All tracts
are mapped with a malleable
metal probe and all cysts, sinuses and fistulae are laid open
Any residual epitheliazed floor is curetted and left open
Excision: Excision of abnormal areas until
only soft normal-appearing
subcutaneous fat remains is the treatment of choice for
extensive stage III
disease. Primary closure should be avoided. Healing by second
intention has the
lowest recurrence rate but closure may take months. Healing may
with skin grafting or VAC closure.