Hydradenitis Suppurativa

DEFINITION
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.

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EPIDEMIOLOGY
Incidence
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
Obesity
Poor hygeine may contribute
Strong association between smoking and perianal disease has been noted.

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AETIOLOGY

Mechanical / Infection superimposed

Pathogenesis

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 keratin plugs.
Trapped secretions then act as a nutritive source for infection to develop.
The gland may subsequently rupture into the dermis and subdermal tissue.
Infection (commonly Bacteroides) may then directly extend through adjacent tissue.

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BIOLOGICAL BEHAVIOUR

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 overlying skin.

Complications
Severe scarring may result from chronic disease.
SCC occasionally arises in such chronically scarred areas.

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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.

Signs
Observe
As above.
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INVESTIGATIONS

Diagnosis is made by clinical appearance.

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MANAGEMENT
Conservative
Weight reduction in the obese.
Improved hygeine.

Pharmacological
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.

Operative

If not responsive to antibiotics.

Acute lesions
:
Local incision and drainage, with oral antibiotics.
Provides relief, but disease often reoccurs.

Chronic disease
:
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.

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What is Hidradenitis Suppurtiva

• Chronic follicular occlusive disease involving intertriginous skin of axillae, groins, perianal, perineal and infra-mammary regions.

• Occlusion of hair follicle (rather than apocrine gland) leading to rupture of follicle with chronic inflammation involving associated structures secondarily (apocrine and eccrine glands)

• Results in formation of subcutaneous abscess, sinuses, scarring and fibrosis

• Bacterial super-infection with strep, staph and coliforms occurs frequently, but cultures from lesions are frequently sterile.

What is the cause

• Unknow

• Causes: obesity, androgen excess or excess androgen end-organ sensitivity, smoking

What is the differential diagnosis

• Follicular pyodermas- folliculitis, furuncles, carbuncles

• Granuloma inguinale

• Crohn’s disease: for perianal or vulval disease

• Acne

How is disease severity assessed

• Hurley staging system

• Stage I: Abscess without sinus or scarring – manage with medical treatement

• Stage II: Recurrent abscesses with sinus tract formation and cicatrisation. Single or multiple widely spaced lesions. – Manage with drug therapy and limited excision of recalcitrant lesions

• Stage III: Diffuse or near-diffuse involvement or multiple interconnected tracts\

How is it treated

• For all patients: avoid tight synthetic clothes, avoid hot humid environments, weight reduction and smoking cessation. Use anti-perspirant.

• Hurley Stage I: Topical Abx (Clindamycin) and intralesional triamcinolone. Systemic oral Abx for resistant cases. Anti-androgen treatment (COCP with spirinolactone for women and dutasteride for men). Zinc glucoate.

• Hurley Stage II: Long-term oral Abx (Rifampicin and Clindamycin). After I&D use oral augemtin for 7 days and the maintenance doxycycline.

• Stage III disease: Surgical intervention with concurrent medical therapy. Pre-operative prednisolone, cyclosporine or infliximab with concurrent clindamycin. Unroofing or deroofing of all cysts with healing by second intention or mesh SSG to aid healing.

What are the surgical options

• I&D: Used for tense abscesses too painful to bear. Wound deeply incised under LA and wound packed. Lesions recur and there is no long-term benefit

• Local or extensive unroofing: All tracts are mapped with a malleable metal probe and all cysts, sinuses and fistulae are laid open using diathermy. 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 be accelerated with skin grafting or VAC closure.