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Skin-nontumor / Clinical Dermatology

Infectious disorders

Hidradenitis suppurativa


Reviewer: Mowafak Hamodat MB.CH.B, MSc., FRCPC, Eastern Health, St. Johns (Canada) (see Reviewers page)
Revised: 24 August 2011, last major update December 2010
Copyright: (c) 2002-2011, PathologyOutlines.com, Inc.

Definition
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● A chronic, relapsing, suppurative inflammation of the terminal hair follicle in areas of apocrine glands: axilla, inguinal folds, perineum, genitalia and periareolar region

Terminology
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● Suggested to called disease acne inversa because first pathogenetic change is in the pilosebaceous follicular ducts, like acne
● Also called Verneuil disease

Etiology
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● Due to bacterial infection around apocrine glands of axilla, occasionally perineum or vulva
● Usually due to anaerobes, which cause an offensive smell
Staphylococcus aureus, Strep Viridans and E. coli are also involved
● Associated with cigarette smoking (Dermatology 1999;198:261) and obesity

Clinical features
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● Initially is a painful nodule of groin or axilla that may involute slowly or produce a foul smelling discharge (due to anaerobes)
● May produce abscess, fistula and scarring
● Late changes are a complex interconnecting system of sinuses extending deeply into the dermis and subcutaneous fat with extensive dense fibrosis
● Patients have increased risk of squamous cell cancinoma of skin, usually men with chronic disease of anogenital region, tumors are HPV related (Dermatology 2010;220:147)
● Staged with Hurley staging system (table)

Treatment
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● Broad-spectrum antibiotic therapy may cause complete remission (Dermatology 2010 Nov 25 [Epub ahead of print])
● Retinoids may induce remission in refractory cases (Br J Dermatol 2010 Sep 27 [Epub ahead of print])
● Variable results with Tumor Necrosis Factor alpha antagonists (negative-Int J Dermatol 2010;49:950, positive-Australas J Dermatol 2010;51:186)
● Excision of involved skin if medical therapy fails (Dermatol Surg 2010;36:1998, Int J Med Sci 2010;7:240)
● Deroofing is a tissue saving surgical technique for mild to moderate lesions (J Am Acad Dermatol 2010;63:475)

Clinical images
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Axilla

Gross / clinical description
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● Abscesses, sinuses, perianal fistulas with scarring

Micro description
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● Heavy neutrophilic or mixed inflammatory infiltrate around apocrine glands with dilated lumina
● Sinus tracts with marked suppuration and frank abscess formation; sinuses are lined by a mixture of granulation tissue and squamous epithelium, which extends from the associated follicular epithelium
● The inflammatory sinus tracts contain desquamated keratin and sometimes hair shafts, and are surrounded by dense fibrosis
● Suppuration may extend into adjacent connective tissue, where there may be a foreign body type reaction of histiocytes and giant cells due to the keratin
● Hyperkeratosis of the terminal follicles (89%), subepidermal cellular inflammatory infiltrate (82%), hyperplasia of follicular epithelium (80%), pronounced perifolliculitis (68%), epidermal psoriasiform hyperplasia (56%), involvement of apocrine glands (52%), involvement of subcutis (31%), follicle rupture (24%, Br J Dermatol 2010 Sep 10 [Epub ahead of print])

Micro images
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Fistula in axilla

Additional references
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eMedicine

End of Skin-nontumor / Clinical Dermatology > Infectious disorders > Hidradenitis suppurativa


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