Hidradenitis suppurativa

Background

• Idiopathic chronic inflammatory skin condition
• Also known as acne inversa or Verneuil disease

Pathophysiology

• Chronic follicular occlusive disease involving the follicular portion of the folliculopilosebaceous units

Epidemiology

• Onset between puberty and age 40
• Slight female predominance
• Increased risk of metabolic syndrome
• Possible association with Crohn disease (more than ulcerative colitis)
• Member of the follicular occlusion tetrad, including acne conglobata, dissecting cellulitis of the scalp, and pilonidal sinus
• May be associated with autoimmune or inflammatory disorders, some malignancies, and genetic disorder

Clinical Manifestations

• Lesions mimic recurrent boils or furuncles
• Predominantly in intertriginous areas, with axillae being most common, but also affecting inguinal area, inner thighs, perianal and perineal areas, mammary and inframammary areas, buttocks, pubic region, scrotum, vulva, trunk, and occasionally the scalp and retroauricular areas

Hurley Clinical Staging

• Stage I: abscess formation (single or multiple) without skin tunnels or cicatrization/scarring
• Stage II: recurrent abscesses with skin tunnels and scarring, single or multiple widely separated lesions
• Stage III: diffuse or almost diffuse involvement, or multiple interconnected skin tunnels and abscesses across the entire area

Differential Diagnosis

• Clinically, consider: follicular pyoderma (including folliculitis, furuncles, and carbuncles), granuloma inguinale, noduloulcerative syphilis, tuberculous abscess, actinomycosis, lymphogranuloma venereum, acne vulgaris, epidermoid/dermoid/pilonidal/Bartholin cysts, Crohn disease
• Histopathologically, consider: granulomatous disease (including Crohn disease, sarcoidosis, mycobacterial infections), chronic deep folliculitis, Langerhans cell histiocytosis, folliculotropic mycosis fungoides, pyoderma gangrenosum, follicular rupture, and abscess

Management

• For mild disease, can consider topical clindamycin or oral tetracycline (as a trial for 2 to 3 months)
  • Can also consider spirolonactone and metformin
• For mild to moderate disease, consider oral tetracycline
• For moderate to severe disease, particularly which does not respond to antibiotics, consider adalimumab
  • Also infliximab, secukinumab, acitretin