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A 25-year-old woman presents with new tender lesions in her axilla (Figure 121-1). She admits to years of similar outbreaks in both axillae 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 121-1

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


Hidradenitis suppurativa (HS) is an inflammatory disease of the pilosebaceous unit in the apocrine gland-bearing skin, specifically the terminal hair. HS is most common in the axilla and inguinal area, but may be found in the inframammary, buttock, and perianal areas as well. It produces painful inflammatory nodules, cysts, and sinus tracts with mucopurulent discharge and progressive scarring. The disease can severely impact quality of life due to pain, odoriferous drainage, and complications such as large abscesses and fistulas.1


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.2

  • Incidence is higher in females, in the range of 4:1 to 5:1. Flare-ups may be associated with menses.2


  • Disorder of the terminal follicular epithelium in the apocrine gland-bearing skin.2

  • Starts with occlusion of hair follicles via hyperkeratosis that leads to occlusion of surrounding apocrine glands and subsequent rupture of the follicular epithelium, releasing sebum, keratin, hairs, and bacteria into the dermis.1

  • Chronic relapsing inflammation and secondary bacterial infection with mucopurulent discharge result.

  • Can lead to sinus tracts, draining fistulas, progressive scarring, and large abscesses (Figures 121-2, 121-3, 121-4, 121-5, 121-6, 121-7).

FIGURE 121-2

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

FIGURE 121-3

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

FIGURE 121-4

Long-standing painful ...

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