Hidradenitis Suppurativa

1. Epidemiology
   1. More common in women by a factor of 4:1
   2. Onset between Puberty and age 40 years
2. Pathophysiology
   1. Inflammation of the Apocrine Sweat Glands
3. Risk Factors
   1. Obesity
   2. Genetic predisposition to Acne Vulgaris
   3. Family History of Hidradenitis Suppurativa
   4. Apocrine duct obstruction
   5. Secondary bacterial infection
   6. Symptomatic flares often occur during Menses
4. Symptoms
   1. Pain, itching, burning and erythema in area involved
5. Signs
   1. Characteristic
      1. Early: Inflammatory Nodule or abscess
      2. Later
         1. Sinus tract formation
         2. Fibrosis
         3. Bridge scarring
         4. Hypertrophic Scar or Keloid
         5. Contractures
         6. Comedones
   2. Distribution
      1. Axilla (more common in women)
      2. Anogenital area (more common in men)
      3. Breasts
      4. Extension onto back and buttocks
6. Differential Diagnosis
   1. Early
      1. Furuncle or Carbuncle
      2. Lymphadenitis
      3. Ruptured Trichilemmal Cyst
      4. Cat Scratch Disease
      5. Tularemia
   2. Late
      1. Lymphogranuloma venereum
      2. Donovanosis
      3. Tuberculosis
      4. Scrofuloderma
      5. Actinomycosis
      6. Ulcerative Colitis fistulae
      7. Regional Enteritis fistulae
7. Associated Conditions
   1. Acanthosis Nigricans
   2. Crohn's Disease
   3. Down Syndrome
   4. Thyroiditis
   5. Hyperandrogenism
   6. Sjogren's Syndrome
8. Management: Mild (Single Nodules with minimal pain)
   1. Avoid exposure to heat and humidity
   2. Avoid shaving if it causes irritation
   3. Avoid synthetic tight fitting clothes
   4. Use antibacterial soaps or hibiclens
   5. Weight loss
   6. Apply warm compresses to affected area
9. Management: Moderate (Recurrent Nodules, pain, abscesses)
   1. Antibiotics for 2 months or more
      1. Axillary involvement
         1. Dicloxacillin
         2. Erythromycin
         3. Tetracycline
         4. Clindamycin Topically (Cleocin-T)
      2. Anogenital involvement
         1. Augmentin or other broad spectrum antibiotic
   2. Other options
      1. Oral Contraceptives (high Estrogen, low androgen)
         1. See Androgenic Activity
      2. Accutane 0.5 to 1 mg/kg PO daily
         1. Used before surgery
      3. Corticosteroids (variable efficacy)
         1. Prednisone 70 mg tapered over 14 days
         2. Intralesional triamcinolone
      4. Cryotherapy
10. Management: Late (abscesses, sinuses, scarring)
    1. Referral to Dermatology
    2. Extensive surgical excision of lesions
11. Complications
    1. Rectal or Urethral fistulas
    2. Secondary infection
    3. Lymphedema
    4. Squamous Cell Carcinoma
12. References
    1. Jansen (1998) Int J Dermatol 37:96-100
    2. Shah (2005) Am Fam Physician 72(8):1547-52