Hidradenitis suppurativa (HS) most commonly affects obese, postpubertal individuals with a genetic predisposition. This unremitting disease involves intertriginous sites: axillae, inguinal folds, gluteal fold, perianal area, and inframammary folds. Lesions begin with erythematous nodules that become tender and fluctuant. The sterile abscess ruptures with a suppurative discharge, and multiple abscesses can eventuate into sinus tracts and/or fistulae. HS is primarily a noninfectious, inflammatory response to the hair follicle; however, secondary infections are common. Severe hypertrophic scar formation may be dramatic and disfiguring. In addition, chronic discharge is difficult to control and commonly malodorous. The differential diagnosis includes bacterial furunculosis, granuloma inguinale, mycetoma, cutaneous tuberculosis, and fistulas associated with inflammatory bowel disease.
Management and Disposition
HS should be identified and local or systemic infection ruled out. Topical and systemic antibiotics help improve lesions, especially if a secondary infection is suspected. Oral doxycycline and minocycline, with topical clindamycin, are common first-line agents. If possible, incision and drainage should be avoided as this can induce chronic sinus tract formation and worsen scarring. Referral to a dermatologist for chronic management and alternative treatments is indicated.
Hidradenitis Suppurativa. Inflammatory abscesses and fistulae in the axilla. (Photo contributor: Stephanie Goldberg, MD.)
Hidradenitis Suppurativa. Axillary scarring and resolving abscesses. (Photo contributor: Stephanie Goldberg, MD.)
Hidradenitis Suppurativa. Chronic inguinal disease and scarring. (Photo contributor: Stephanie Goldberg, MD.)
HS is not a primary infectious process but rather inflammatory. This often leads to delayed diagnosis, worse skin involvement, and permanent scarring.
Identifying presentations of HS and promptly referring them to dermatology can minimize long-term morbidity.
Perianal involvement should prompt gastroenterology referral to rule out inflammatory bowel disease.
Patients with long-term disease are at risk for developing squamous cell carcinomas in the affected areas.