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Hidradenitis Suppurativa

  • Hidradenitis suppurativa (HS) is a chronic inflammatory process affecting skin bearing apocrine glands; the groin, axillae, and inframammary areas are typically involved.
  • The classic lesions of HS include cysts, nodules, sinus tracts, and inflamed abscesses. In rare cases, lesions of pyoderma gangrenosum can occur concurrently within areas of HS or at distant sites.
  • Hidradenitis suppurativa is more prevalent in women. Risk factors for disease include obesity, smoking, and Crohn’s disease. Additional cutaneous associations include acne, pilonidal cyst, acne conglobata, and dissecting cellulitis of the scalp (also known as the follicular occlusion tetrad).
  • Lesions of HS must be monitored for development of squamous cell carcinoma.
  • Progression is often relentless and defies medical management. Early surgery for local and widespread lesions is sometimes the best alternative.

Introduction

Hidradenitis suppurativa (HS) is a chronic inflammatory process that affects skin bearing apocrine glands, typically involving the groin, axillae, and inframammary areas. Areas affected by HS are characteristically marked by heterogeneous skin lesions, ranging from cysts, nodules, sinus tracts, and inflamed abscesses. In rare cases, lesions of pyoderma gangrenosum can occur concurrently within areas of HS or at distant sites.

Women are typically more commonly affected than males and the axilla is the most common site of involvement. A family history of HS is not unusual, and in one small patient cohort, mutations in the gamma secretase complex were identified. Risk factors for disease include obesity, smoking, and Crohn’s disease. Additional cutaneous associations include acne, pilonidal cyst, acne conglobata, and dissecting cellulitis of the scalp (also known as the follicular occlusion tetrad). Lesions of HS must be monitored for development of squamous cell carcinoma, which evolve at sites of chronic inflammation (Marjolin’s ulcer) and in HS, typically occur on the buttocks.

Progression is often relentless and defies medical management. Early surgery for local and widespread lesions is sometimes the best alternative. Hidradenitis suppurativa has a profound impact on patient quality of life. The medical management should be tailored towards the severity and distribution of the disease. Local, mild disease may be managed with topical antibiotics or intralesional corticosteroid injections alone. More severe, extensive disease may require systemic therapy, including short courses of systemic antibiotics and anti-androgen therapy for female patients. Systemic retinoids have not been found to be helpful in this disease. For severe cases of HS, especially with concurrent lesions of pyoderma gangrenosum, systemic immunosuppression with anti-TNF inhibitors may be the best option, though data is limited. To date, the evidence best supports use of antibiotics and TNF-blockade; the use of anti-androgens is only recommended for women with mild to moderate HS who have previously failed antibiotics or have evidence of hyperandrogenism.