14 Hidradenitis suppurativa (HS) is a chronic inflammatory disease mainly occurring in areas where apocrine glands are commonly situated – the axillae, inguinal folds, perineum, genitalia and breasts. It is characterized by recurrent inflammatory nodules, abscesses and sinus formation with scarring. In some patients the clinical features may overlap with those of Crohn’s disease and painful axillary lesions are reported in 17% of those with Crohn’s disease. Hidradenitis suppurativa is more common in women and usually starts after puberty. The disease may be most active among individuals in their 30s and 40s. Genital and inguinal lesions are more common in females. Risk factors include smoking and obesity. The global prevalence is 1% but the point prevalence can be up to 4% in young females. An autosomal dominant mode of inheritance has been identified and many patients will give a positive family history of HS, acne or pilonidal sinuses. The exact pathogenesis is not clear but the evidence points to follicular inflammation, which then progresses to scarring and sinus tract formation. The main pathology is inflammation but infection is very common as a secondary problem. The diagnosis is usually made on the classic clinical features. Histological examination shows sinus tracts lined with granulation tissue and squamous epithelium and surrounded by fibrosis. Abscess formation and suppuration are common and this suppuration can extend deep into the connective tissue with an associated marked inflammatory infiltrate. Pain is usually the most reported symptom. When the lesions discharge, this can be malodorous and offensive. In females, there is often a premenstrual flare of symptoms. Hidradenitis suppurativa has a significant negative effect on quality of life and is reported to have more of an impact than severe psoriasis and eczema. Depression, fatigue and a chronic anaemia are seen. There is an increased incidence of inflammatory bowel disease, spondyloarthropathies and pyoderma gangrenosum. The characteristic features are deep‐seated nodules and abscesses in the axillae, groins and vulva (Figure 14.1). The breasts, inframammary areas and buttocks may be involved with extension on to the thighs in severe cases. Some of the nodules may have an overgranulated appearance and bridged comedones are often seen (Figure 14.2). Squamous cell carcinoma has been reported to occur in severe HS but is more common in males. The perineum is a common site. Figure 14.1 Hidradenitis suppurativa – vulval involvement. Figure 14.2 Bridged comedones. A clinical grading system (Hurley stages 1–3) is useful to score disease severity (Table 14.1). Table 14.1 Hurley staging system for hidradenitis supparativa. Weight reduction and stopping smoking are very important as general measures. Further management is then based on the stage of the disease. Topical antibiotic treatment such as topical clindamycin 1%, may be sufficient but this needs to be used for at least 12 weeks. Oral treatment is usually required and the first‐line treatment is oral antibiotics. Tetracyclines are most commonly used for their anti‐inflammatory properties, for example oxytetracycline 500 mg bd or lymecycline 408 mg od or bd. Patients must be counselled to avoid pregnancy while taking these drugs as they can affect the development of the bones and teeth in the foetus.
Hidradenitis Suppurativa and Crohn’s Disease
Hidradenitis Suppurativa
Introduction
Epidemiology
Incidence
Pathophysiology
Histological features
Symptoms
Clinical features
Hurley stage
Clinical features
I
Single or multiple nodules or abscesses but without scarring or sinus tracts
II
Recurrent abscesses with single or separate sinus tracts
III
Diffuse involvement with multiple interconnected abscesses
Basic management
Medical management
Stage I disease
Stage II disease
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