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-
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
Perianal region
Infra-mammary region
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
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
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
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.
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
Recurrent abscess formation and formation of chronic sinus and tracts with recurrence are the usual
indications for surgery.
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.
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 relapsingstage 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
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.
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
Marjolin ulcer (squamous cell carcinoma) has been reported in long-standing chronic
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
Reassessment for several months in the follow-up clinic is required before cure can be assumed with
Alexander SJ: Squamous cell carcinoma in chronic hydradenitis suppurativa: a case
report. Cancer 1979 Feb; 43(2): 745-8.
Barth JH, Layton AM, Cunliffe WJ: Endocrine factors in pre-
and postmenopausal women
with hidradenitis suppurativa. Br J Dermatol 1996 Jun; 134(6): 1057-9.
Bell BA, Ellis H: Hydradenitis suppurativa. J R Soc Med 1978 Jul; 71(7): 511-5
Bhalla R, Sequeira W: Arthritis associated with hidradenitis suppurativa. Ann Rheum Dis
1994 Jan; 53(1): 64-6.
Brook I, Frazier EH: Aerobic and anaerobic microbiology of axillary hidradenitis
suppurativa. J Med Microbiol 1999 Jan; 48(1): 103-5.
Brown TJ, Rosen T, Orengo IF: Hidradenitis suppurativa. South Med J 1998 Dec; 91(12):
Conway H: Surgical treatment of chronic hidradenitis suppurativa. Surg Gynaecol Obstet
1952; 95: 455-463.
Dvorak VC, Root RK, MacGregor RR: Host-defense mechanisms in hidradenitis
suppurativa. Arch Dermatol 1977 Apr; 113(4): 450-3.
Finley EM, Ratz JL: Treatment of hidradenitis suppurativa with carbon dioxide laser
excision and second-intention healing. J Am Acad Dermatol 1996 Mar; 34(3): 465-9.
Fitzsimmons JS, Guilbert PR, Fitzsimmons EM: Evidence of genetic factors in
hidradenitis suppurativa. Br J Dermatol 1985 Jul; 113(1): 1-8
Frohlich D, Baaske D, Glatzel M: [Radiotherapy of hidradenitis suppurativa--still valid
today?]. Strahlenther Onkol 2000 Jun; 176(6): 286-9.
Harrison BJ, Kumar S, Read GF: Hidradenitis suppurativa: evidence for an endocrine
abnormality. Br J Surg 1985 Dec; 72(12): 1002-4
Highet AS, Warren RE, Weekes AJ: Bacteriology and antibiotic treatment of perineal
suppurative hidradenitis. Arch Dermatol 1988 Jul; 124(7): 1047-51.
Hogan DJ, Light MJ: Successful treatment of hidradenitis suppurativa with acitretin. J Am
Acad Dermatol 1988 Aug; 19(2 Pt 1): 355-6.
Jemec GB, Faber M, Gutschik E: The bacteriology of hidradenitis suppurativa.
Dermatology 1996; 193(3): 203-6.
Jemec GB: Long-term results of isotretinoin in the treatment of 68 patients with
hidradenitis suppurativa. J Am Acad Dermatol 1999 Oct; 41(4): 658.
Jemec GB, Heidenheim M, Nielsen NH: The prevalence of hidradenitis suppurativa and
its potential precursor lesions. J Am Acad Dermatol 1996 Aug; 35(2 Pt 1): 191-4
Jemec GB: The symptomatology of hidradenitis suppurativa in women. Br J Dermatol
1988 Sep; 119(3): 345-50
Joseph MA, Jayaseelan E, Ganapathi B: Hidradenitis suppurativa treated with finasteride.
J Dermatolog Treat 2005 Apr; 16(2): 75-8.
Konig A, Lehmann C, Rompel R: Cigarette smoking as a triggering factor of hidradenitis
suppurativa. Dermatology 1999; 198(3): 261-4.
Kurzen H, Jung EG, Hartschuh W: Forms of epithelial differentiation of draining sinus in
acne inversa (hidradenitis suppurativa). Br J Dermatol 1999 Aug; 141(2): 231-9.
Lane JC: hidrosdenitis axillare of Verneuil. Arch Dermatol Sphilol 1939; 39: 108.
Lapins J, Sartorius K, Emtestam L: Scanner-assisted carbon dioxide laser surgery: a
retrospective follow-up study of patients with hidradenitis suppurativa. J Am Acad
Dermatol 2002 Aug; 47(2): 280-5.
Letterman G, Schurter M: Surgical treatment of hyperhidrosis and chronic hidradenitis
suppurativa. J Invest Dermatol 1974 Jul; 63(1): 174-82.
Melkun ET, Few JW: The use of biosynthetic skin substitute (Biobrane) for axillary
reconstruction after surgical excision for hidradenitis suppurativa. Plast Reconstr Surg
2005 Apr 15; 115(5): 1385-8.
Mortimer PS, Dawber RP, Gales MA: A double-blind controlled cross-over trial of
cyproterone acetate in females with hidradenitis suppurativa. Br J Dermatol 1986 Sep;
115(3): 263-8.
Moschella SL: Hidradenitis suppurativa. Complications resulting in death. JAMA 1966 Oct
3; 198(1): 201-3.
Mustafa EB, Ali SD, Kurtz LH: Hidradenitis suppurativa: review of the literature and
management of the axillary lesion. J Natl Med Assoc 1980 Mar; 72(3): 237-43.
O'Loughlin S, Woods R, Kirke PN: Hidradenitis suppurativa. Glucose tolerance, clinical,
microbiologic, and immunologic features and HLA frequencies in 27 patients. Arch
Dermatol 1988 Jul; 124(7): 1043-6.
Paletta F X: Hidradenitis suppurativa: pathological study and use of skin flaps. Plast
Reconstr Surg 1963; 31: 307.
Pollock WJ, Virnelli FR, Ryan RF: Axillary hidradeniti
s suppurativa. A simple and effective
surgical technique. Plast Reconstr Surg 1972 Jan; 49(1): 22-7.
Ramasastry SS, Conklin WT, Granick MS: Surgical management of massive perianal
hidradenitis suppurativa. Ann Plast Surg 1985 Sep; 15(3): 218-23.
Ritz JP, Runkel N, Haier J: Extent of surgery and recurrence rate of hidradenitis
suppurativa. Int J Colorectal Dis 1998; 13(4): 164-8
Rompel R, Petres J: Long-term results of wide surgical excision in 106 patients with
hidradenitis suppurativa. Dermatol Surg 2000 Jul; 26(7): 638-43
Rose RF, Goodfield MJ, Clark SM: Treatment of recalcitrant hidradenitis suppurativa with
oral ciclosporin. Clin Exp Dermatol 2006 Jan; 31(1): 154-5.
Shelly WB, Cahn: Pathogenesis of hidradenitis suppurativa in man. Experimental and
histological observations. Arch Dermatol 1955; 72: 562.
Stellon AJ, Wakeling M: Hidradenitis suppurativa associated with use of oral
contraceptives. BMJ 1989 Jan 7; 298(6665): 28-9.
Sullivan TP, Welsh E, Kerdel FA: Infliximab for hidradenitis suppurativa. Br J Dermatol
2003 Nov; 149(5): 1046-9
Tennant F Jr, Bergeron JR, Stone OJ: Anemia associated with hidradenitis suppurativa.
Arch Dermatol 1968 Aug; 98(2): 138-40.
Trent JT, Kerdel FA: Tumor necrosis factor alpha inhibitors for the treatment of
dermatologic diseases. Dermatol Nurs 2005 Apr; 17(2): 97-107.
Venturini R, Ruggieri V, Stellar A: The after-effect of movement induced with a rotating
spiral (spiral after-effect): reliability and correlation with personality characteristics. Boll
Soc Ital Biol Sper 1974 Feb 15; 50(3): 118-24.
Verneuil AS: Etudes sur les tumor de la peau. Arch Gen Med 1854; 94: 693.
Von Der Werth JM, Williams HC, Raeburn JA: The clinical genetics of hidradenitis
suppurativa revisited. Br J Dermatol 2000 May; 142(5): 947-53