M62 Coloproctology Course

The Keynote speaker was Steve Wexner from the Cleveland Clinic and John Northover from St. Marks was the ACPGBI President.

Text Size

Hidradenitis Suppurativa

Nigel A Scott

Powerpoint File

Definition

Painful, inflamed lesions in the axillae, groin, and other parts of the body that contain apocrine glands (from the Greek hidros=sweat and aden=glands)

The disease is a chronic acneiform infection of the cutaneous apocrine glands that also can involve adjacent subcutaneous tissue and fascia. The hallmark of the disease is sinus tracts (which can become draining fistulas) in the apocrine gland body areas.

 

  • Common involves 1-2% of the population, but the precise incidence and prevalence are unknown. [Embarassing condition, often inadequately managed that leads to considerable patient resentment and unhappiness]
  • 4F:1M
  • Any age after puberty – peak incidence in the second and third decades, declining rapidly by the fifth decade.

Pathophysiology


The most likely mechanism responsible for the development of Hidradenitis is occlusion of the hair follicle (rather than the apocrine gland) due to a defect in terminal follicular epithelium.

After the plugging occurs, bacteria invade the apocrine system via the hair follicles, become trapped beneath the keratinous plugs, and multiply rapidly in the apocrine sweat. The glands subsequently rupture and spread the infection to adjacent apocrine and eccrine glands, further extending the tissue destruction and skin damage.
The significance of bacterial infection in Hidradenitis is controversial. Although bacterial superinfection with streptococci, staphylococci, and coliforms are considered part of the pathogenesis of the disorder, cultures from lesions are frequently sterile and antibiotics are not curative

  • Androgens

In women high androgen levels have been suggested as an aetiological factor in women. However, there was no evidence of such an association when women with hidradenitis were compared with controls matched for weight and hirsutism. Moreover hidradenitis is predominantly a female disease.

Clinical picture

This condition involves:

  • Axillae.
  • Periareolar, intermammary zones.
  • Pubic area.
  • Infraumbilical midline.
  • Gluteal folds.
  • Genitofemoral areas (top of the thighs in genital area).
  • Perianal region.
Area(s) of involvment Male (n=15) Female (n=42) P Value
Axilla 2 (13%) 37 (88%) <.0001
Unilateral 1 (50) 19 (51)  NS
Bilateral 1 (50) 18 (49)   
Inguinoperineal 13 (87%) 5 (12) <.0001 
Unilateral 1 (8) 4 (80) .0131
Bilateral 12 (92) 1 (20)   
 Axilla and Inguinoperineal 1 (7) 3 (8) Ns 
 
 
 
 
 
 
 
 
 
 
 

Characterised by multiple red, hard, raised nodules in areas where apocrine glands are concentrated, cellulitis, chronic suppuration with thick sinus tracks and draining fistulae. Three stages are recognised:
Stage I. Solitary or multiple isolated abscess formation without scarring or sinus tracts;
Stage II. Recurrent abscesses, single or multiple widely separated lesions, with beginning sinus tract formation ("tunneling") and cicatrisation (formation of scar tissue);
Stage III. Diffuse or broad involvement across a regional area with multiple interconnected sinus tracts, significant cicatrisation and persistent abscesses.


Medical Management

  • Long-term antibiotics:
    • Long-term administration of erythromycin and tetracycline has been used to treat the chronic stages and is shown to reduce the relapse rate. Initial treatments are usually oral antibiotics (tetracycline, erythromycin, Augmentin,) and topical antibiotics (clindamycin or erythromycin)
  • Estrogens:
    • Contraceptive pills (eg, 50 mcg ethynyl estradiol) and the combination of estrogens with 100 mg of cyproterone acetate have been used.
  • Retinoids:
    • These have been shown to be effective in the chronic disease. Isotretinoin, at a dose of 1 mg/kg/d, is administered for 4 months.. Retinoids are teratogenic, and pregnancy is prevented by the use of contraception. Approximately 40% of patients show good response to retinoids.

Surgical Management

Established sinus tracts and extensive lesions of advanced cases respond only to en bloc surgical excision. Extensive areas of hidradenitis require wide excision of apocrine gland bearing skin. This may obviate the possibility of primary closure and so require either skin grafting or healing by secondary intention.

REFERENCES

Stewart EG. Hidradenitis suppurativa UpToDate v14.3

Mortimer PS, Lunniss PJ. Hidradenitis supprativa J R Soc Med 2000;93:420-422

Barth, JH, Layton, AM, Cunliffe, WJ. Endocrine factors in pre- and postmenopausal women with hidradenitis suppurativa. Br J Dermatol 1996; 134:1057

Boer, J, van Gemert, MJP. Long-term results of isotretinoin in the treatment of 68 patients with hidradenitis suppurativa. J Am Acad Dermatol 1999; 40:73.

Jemec, GB, Wendelboe, P. Topical clindamycin versus systemic tetracycline in the treatment of hidradenitis suppurativa. J Am Acad Dermatol 1998; 39:971

Rompel R, Petres J. Long-Term Results of Wide Surgical Excision in 106 Patients with Hidradenitis Suppurativa Dermatologic Surgery Vol. 26 Issue 7 Page 638 July 2000

Kagan et al. Surgical treatment of hidradenitis suppurativa: A 10-year experience
Surgery 2005:138(4);734-741.

To register fill in the registration form and send it off complete with a cheque to pay for your course.

Course Fee: £240

Mr J Hartley
Consultant Surgeon
Academic Surgical Unit
Castle Hill Hospital
Cottingham
East Yorkshire
HU16 5JQ

Download the PDF Registration form