Hidradenitis Suppurativa

What is hidradenitis suppurativa?

Hidradenitis is characterized by small or large, tender, red nodules beneath the surface of the skin. The areas most often affected are the underarm, groin, and perirectal skin although many other regions may also be affected. The drainage is often pussy (to "suppurate" means to create pus, ergo the name of the condition). One characteristic hallmark of the condition is that pressure on one nodular area may produce drainage from a distant site. It frequently leads to scarring in the affected areas.


How long has the condition been recognized?

The condition has been identified as a specific disease since 1839. Early descriptions focused on glandular irregularities within affected areas, and it was thought to represent an infection of the "sweat" glands. Even within the 20th Century, suggested causes revolved around the apocrine, or scent glands. More recently, attention has been directed to the follicle or pore as the point of origin.

What is the cause of hidradenitis?

Initially, the presence of pus suggested an infectious process. However cultures for bacteria were consistently unremarkable. Current data suggests that this condition starts with inflammation within the pore. The pore ruptures, leading to the development of tunnels and pockets of purulent drainage beneath the skin. Healing from these lesions may form cords or bands of scarring as the body tries to build a "wall" around the regions of inflammation.

What are other features of hidradenitis?

Frequently hidradenitis may be seen in an individual that has also experienced significant acne. Occasionally, a family history of the condition may be present. Less commonly, there may be boils present within the scalp (a condition referred to as folliculitis decalvans), or a boil-like lesion present at the base of the spine referred to as a pilonidal cyst.

In some patients, worsening with hormonal cycling has occurred. However hormone levels are generally normal. Patients who are overweight or of African American heritage may be more severely affected. Cancerous change within the skin lesions has been reported but is quite rare. It is not associated with internal cancers.

How is hidradenitis treated?

Hidradenitis may be divided into early and late stages. In the early phase of hidradenitis, patients may experience individual tender nodules, usually without communication with other pores. With time, many persons will experience tunneling with multiple tender, red nodules connecting below the skin surface. The drainage of pus from either solitary or multiple lesions is characteristic. Tenderness and a foul odor are very common.

Treatment for early stages of hidradenitis may focus on control the inflammation. Oral antibiotics, injections of antibiotics or cortisones, anti-inflammatory medications (such as dapsone, steroids, or "the Biologics") can be helpful. Hormonal blocking medications such as finasteride, spironolactone, or cyproterone acetate have been used, with occasional good results. Retinoids such as Accutane have been inconsistent in their benefits.

Late stage disease, in which there are tunnels below the surface of skin has primarily necessitated removal of the inflamed and communicating areas. Excision, with or without skin grafting, has been occasionally proposed. Lancing of affected areas may produce temporary relief, but can lead to additional tunnels. Recently, excellent results have been obtained using the carbon dioxide laser. This technique, usually performed under local anesthesia, allows for removal of all affected tissue and is able to produce acceptable qualities of healing and long-lasting clearing of the process. The technique has been referred to as "carbon dioxide laser excision and marsupialization".

How is carbon dioxide laser excision and marsupialization performed?

The procedure is generally carried out using local anesthetics. After cleansing of the area, an injection of Novocain-like anesthesia is given. The laser, which is a very intense and focused light, is then used to cut around and beneath the tender boil-like areas. The laser has the ability to seal small blood vessels. Blood loss is therefore usually minimal. In addition, the laser allows visualization of the affected area, allowing identification of hidden tunnels which are then also removed.

Following removal, a simple dressing is placed. Medications are suggested for care of the wound. Healing is usually complete in 8-9 weeks. The healing process is generally comfortable although a dressing is normally used throughout.


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