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A 25-year-old woman presents with new tender lesions in her axilla (Figure 115-1). She admits to years of similar outbreaks in both axilla and occasional painful bumps in the groin. She states that it is painful to have them opened and just wants to get some relief without surgery. We elected to inject the nodules with triamcinolone and start the patient on doxycycline 100 mg twice daily. Smoking cessation was emphasized and the patient agreed to start on a nicotine patch that evening. She had relief within 24 hours from the steroid injection.

Figure 115-1

Mild hidradenitis suppurativa in the axilla of a young woman. She has a history of recurrent lesions in her axilla. (Courtesy of Richard P. Usatine, MD.)

Hidradenitis suppurativa (HS) is an inflammatory disease of the pilosebaceous unit in the apocrine gland-bearing skin. HS is most common in the axilla and inguinal area, but may be found in the inframammary area as well. It produces painful inflammatory nodules, cysts, and sinus tracks with mucopurulent discharge and progressive scarring.

It is called acne inversa because it involves intertriginous areas and not the regions affected by acne (similar to inverse psoriasis).

  • Occurs after puberty in approximately 1% of the population.1
  • Incidence is higher in females, in the range of 4:1 to 5:1. Flare-ups may be associated with menses.1

  • Disorder of the terminal follicular epithelium in the apocrine gland-bearing skin.1
  • Starts with occlusion of hair follicles that lead to occlusion of surrounding apocrine glands.
  • Chronic relapsing inflammation with mucopurulent discharge (Figures 115-2, 115-3, 115-4, 115-5, 115-6, 115-7).
  • Can lead to sinus tracts, draining fistulas and progressive scarring (Figures 115-2, 115-3, 115-4, 115-5, 115-6, 115-7).

Figure 115-2

Moderate HS in a young woman. The lesions are deeper and there have been some chronic changes with scarring and fibrosis from previous lesions. (Courtesy of Richard P. Usatine, MD.)

Figure 115-3

A 33-year-old Hispanic woman with sinus tracts, draining fistulas, and scarring secondary to her chronic HS. Note the mucopurulent discharge. (Courtesy of Richard P. Usatine, MD.)

Figure 115-4

Longstanding painful severe HS between the breasts of a 45-year-old woman. (Courtesy of Richard P. Usatine, MD.)

Figure 115-5

Severe disabling HS in a 34-year-old white man who is morbidly obese. He finds it painful to walk. (Courtesy of Richard P. Usatine, MD.)

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