R. Wayne Whitted MD, MPH
8740 N Kendall Dr. Suite 101
Miami, Florida 33176
Phone: 305-596-3744
www.floridaamigos.com Hydradenitis Suppurativa
Hidradenitis suppurativa is a chronic, recurring, abscessing disease occurring in the apocrine follicles
and sweat glands. The disease tends to become chronic because of subcutaneous extension leading to
induration, sinus, and fistula formation.
In the US: Hidradenitis suppurativa occurs more commonly in women and usually occurs in the third
decade of life. One study by Brown et al determined the prevalence in industrialized countries to be 0.3-
4%.
Frequency:
Internationally: The prevalence has not been accurately determined. The disease is found more
commonly in the white and the black populations and is rarely observed in the Asian population.
Age: Hidradenitis suppurative usually begins in the postpubertal age group, when the apocrine glands
start developing. It is most common in the third decade of life, but the untreated disease may persist into
the seventh decade.
Sex: The condition is more common in women. Sub-breast, armpit, and inguinal involvement is more
common in females, whereas the perineal form is more common in men.
Site: Hidradenitis suppurative is found in the following areas:
• Skin-bearing apocrine glands
• Axilla
• Groin
• Perineum
• Perianal region
• Buttocks
• Scrotum
• Infra-mammary region
Etiology:
• Folliculitis is observed in all patients with hidradenitis suppurativa; whether this is
coincidental or causative has not been established.
The exact cause of hidradenitis suppurativa has not been determined, although the following
theories have been proposed:
• Local frictional trauma has been proposed to be one of the causative factors.
• Infective etiology
o Streptococci, staphylococci, and Escherichia coli
have been identified in the early
stages of the disease; however, in the chronic relapsing stages, anaerobic
bacteria and Proteus
o Whether the bacteria are the cause or the result of the disease has not been
determined.
species have more commonly been isolated.
• Diabetes, impaired glucose intolerance, and obesity were observed in some patients
with hidradenitis. Studies have shown that these entities are only incidental findings and
not causative.
• Hormonal theory: Improvement and relapse after pregnancy and contraceptive pill
intake suggest that low levels of estrogens cause a predisposition for hidradenitis
suppurativa.
• Immune theory: Immunity in most patients is intact, but some patients demonstrate a
defect in the T-cell lymphocytes.
• Genetic theory: Increased incidence in individuals with HLA-A1 and HLA-B8 has been
demonstrated in some patients.
• Association tetrads: Hidradenitis is part of the tetrad of acne conglobata (cystic acne),
pilonidal sinus, and perifollicular capitis.
• Cigarette smoking and lithium therapy have been identified as triggering factors for the
disease.
Process of formation of condition:
Keratin comedones
↓
Occlusion of the apocrine ducts
↓
Superimposed inflammation and infection
↓
Abscess formation
↓
Chronic infection and spread
↓
Induration and sinus and fistula formation
The early lesions are solitary, painful pruritic nodules that may persist for weeks or months without any
change. If subcutaneous extension occurs, it may appear as indurated plaques, which in lax skin, such as
the axilla and groin, manifest as linear bands. Multiple sites may be simultaneously affected.
Clinical:
The nodules develop into pustules and eventually rupture externally, draining purulent material. Healing
occurs with dense fibrosis, and recurrences crop up in and around the original site. This leads to chronic
sinus formation, with intermittent release of serous, purulent, or bloodstained discharge. Ulceration
sometimes occurs, and the abscesses may burrow and rupture into the neighboring structures. Episodes
of acute cellulitis are sometimes a feature and are accompanied by fever.
Regional enlarged lymph nodes are characteristically absent. Chronic axillary hidradenitis suppurativa
usually causes a reduction of the normal axillary odor.
Severity and course of the disease are variable, but untreated hidradenitis suppurativa is typically a
relentless progressive disease with acute exacerbations and remissions that lead to sinus tract formation
and marked scarring.
Differential diagnoses include the following conditions:
• Infected cystic acne
• Lymphogranuloma venereum
• Developmental fistulae
• Crohn disease
• Furunculosis
• Scrofuloderma
• Actinomyces
Recurrent abscess formation and formation of chronic sinus and tracts with recurrence are the usual
indications for surgery.
Contraindications:
The acute abscess stage is a relative contraindication for curative surgery, which
can be performed subsequent to a short course of antibiotic therapy.
• Blood tests
Lab Studies:
o A complete blood cell count identifies the underlying anemia associated with the
chronic disease.
o Blood sugar tests identify associated diabetes.
• Microbiology
o In the acute stages, the isolated organisms include the coagulase negative
staphylococci, E coli, Streptococcus milleri, and the anaerobic Bacteroides
species. Proteus
o Staphylococci have been shown to be the transient bacteria in the acute initial
stages, whereas
species have been isolated from patients with chronic conditions.
S milleri
is the predominant organism in the chronic stages.
Staging: The disease can be divided into the following 3 clinical stages:
•
Stage 1: Single or multiple abscesses form, without sinus tracts and scarring.
• Stage 2: Recurrent abscesses form, with tract formation and scarring. There may be
single or multiple widely separated lesions.
• Stage 3: Diffuse or near-diffuse involvement or multiple interconnected tracts and
abscesses are observed across the entire area.
Medical therapy:
Nonspecific treatment measures include good hygiene, weight reduction, use of antiseptic detergents, and
avoidance of tight-fitting clothes.
Treatment depends upon the stage of the disease. Early lesions are usually treated by
medical therapy, whereas the patient with long-standing indolent disease requires surgical therapy.
• Acute-stage treatment options
o Antibiotics: A short course of antibiotics for a period of 2 weeks is usually
advisable. The antibiotics used include a combination of erythromycin and
metronidazole, minocycline, or clindamycin. Cephalosporins and penicillins can
also be used.
o Intralesional steroids: Intralesional injection of steroids (eg, triamcinolone 5-10 mg
diluted with water) causes the early lesions to involute within 12-24 hours.
• Chronic relapsing–stage treatment options
o Long-term antibiotics: Long-term administration of erythromycin and tetracycline
has been used to treat the chronic stages and is shown to reduce the relapse rate
.
However, the efficacy of the antibiotics may be lost after long-term use. Efficacy
can usually be regained by stopping the drug for a month and restarting it.
o High-
dose systemic steroids (eg, prednisolone 60 mg/d) are useful as adjuvants to
antibiotics, and they act by reducing the inflammatory process.
o Estrogens: Contraceptive pills (eg, 50 mcg ethynyl estradiol) and the combination
of estrogens with 100 mg of cyproterone acetate have been used.
o Retinoids: These have been shown to be effective in the chronic disease.
Isotretinoin, at a dose of 1 mg/kg/d, is administered for 4 months. Etretinate, at a
dose of 0.5 mg/kg/d for a period of 6 months, is used for patients whose conditions
are unresponsive to isotretinoin. Retinoids are teratogenic, and pregnancy is
prevented by the use of contraception. Approximately 40% of patients show good
response to retinoids.
• Other therapeutic agents that have been used with limited success include cisplatin,
methotrexate, 5-alpha reductase inhibitors, and TNF-alpha inhibitors. Infliximab has been
used in patients having Crohn disease and associated hidradenitis suppurativa.
• Stage 1 options include incision and drainage, followed by antibiotics.
Surgical therapy:
• Stage 2 and some stage 3 options include minor procedures.
o Exteriorization and laying open of tracts and electrocoagulation
o Excision and primary closure, such as the Pollock procedure
•
Stage 3 options include total wide excision and healing with secondary intention or flaps
and grafts.
• Closure of defects is achieved by the following:
o Z-plasty
o Skin grafts
Thiersch split-thickness grafts
Meshed grafts
Wolfe full-thickness grafts
o Flaps
Rotation flaps
Free flaps
o Biosynthetics agents, like Biobrane and Integra, have also been recently used.
• Be aware of the possibility of associated systemic abnormalities.
Preoperative details:
• Perform routine preoperative assessment for surgery and anesthesia, including cardiac,
respiratory, and renal assessments.
• Order antibiotics to treat the acute exacerbations before surgery.
• Order prophylactic antibiotics before surgery.
• Warn patients of the likelihood of a large raw area, which will require prolonged
postoperative dressings.
• Perform a wide excision, with a margin of 1.5 cm all around the lesion.
Intraoperative details:
• Perform intraoperative mapping of the sinus tracts with methyl violet, which reduces
recurrence rates.
• In the genital and perianal area, primary closure is to be avoided, and healing by
secondary intention is advocated.
• Axilla: Total excision with
transverse primary closure (ie, the Pollock procedure) is usually
possible.
• Postoperative care
Postoperative details:
o Regular and prolonged use of postoperative dressings is necessary to aid
secondary healing.
o Healing can be hastened by the use of silastic foam dressings.
o Use of Betadine and chlorhexidine dressings and compression have been shown
to be of benefit.
• Postoperative complications
o Patients can develop general complications such as pneumonia, deep venous
thrombosis (DVT), and infection. Administer routine perioperative DVT and
antibiotic prophylaxis.
o Active physiotherapy, breathing exercises, and early ambulation are encouraged.
o Postoperative complications specific to the procedure include wound breakdown,
hematoma formation, wound infection, and graft rejection and failure.
o
The overall complication rate is 17-20%.
Follow-up care:
The complications of long-standing untreated disease include the following:
Patients are monitored in the clinic at regular intervals for at least 6 months before they
can be declared to be cured.
• Fistulae formation into the urethra, bladder, rectum, or peritoneum has been reported.
• Sequelae of chronic infection such as secondary anemia, hypoproteinemia, amyloidosis,
and renal disease can occur in chronic disease.
• Joint disease.
• Chronic fatigue and depression are observed.
• Scarring of the tissue can lead to lymphatic obstruction and swelling of the limbs and
joints
• Marjolin ulcer (squamous cell carcinoma) has been reported in long-standing chronic
disease.
• Scrotal elephantiasis has been reported.
Recurrence does arise, and reported rates vary by 30-
50%. One series reports a 100% recurrence rate with
incision and drainage alone, 42% recurrence with limited excision, and 27% recurrence after radical
excision.
Reassessment for several months in the follow-up clinic is required before cure can be assumed with
certainty.
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