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Hidradenitis Suppurativa

Hidradenitis suppurativa is a chronic suppurative and scarring disease of the skin and subcutaneous tissue occurring in the axillae, the anogenital regions, and under the female breast. There is a great variation in clinical severity. Many cases, especially of the thighs and vulva, are mild and misdiagnosed as recurrent furunculosis. The disease is worse in the obese. One study reported inflammatory arthropathy in several patients with hidradenitis suppurativa and acne conglobata. Clinical and laboratory findings were similar to those seen in other seronegative spondyloarthropathies.

Clinical presentation.

A hallmark of hidradenitis is the double comedone, a blackhead with two or sometimes several surface openings that communicate under the skin. This distinctive lesion may be present for years before other symptoms appear. Unlike acne, once the disease begins it becomes progressive and self-perpetuating. Extensive, deep, dermal inflammation results in large, painful abscesses. The healing process permanently alters the dermis. Cordlike bands of scar tissue criss-cross the axillae and groin.


Antiperspirants, shaving, chemical depilatories, and talcum powder are probably not responsible for the initiation of the disease.  Tretinoin cream (0.05%) may prevent duct occlusion, but it is irritating and must be used only as tolerated. Large cysts should be incised and drained, whereas smaller cysts respond to intralesional injections.

Actively discharging lesions should be cultured. Repeated bacteriologic assessment is advisable in all cases. The laboratory should be instructed to look specifically for Streptococcus milleri and anaerobes and to assess sensitivity to erythromycin and tetracycline.


Antibiotics are the mainstay of treatment, especially for the early stages of the disease. As with acne vulgaris, long-term oral antibiotics such as tetracycline (1 gm daily), erythromycin (1 gm daily), or minocycline (200 mg daily) may prevent disease activation. High dosages, such as 500 mg of erythromycin four times daily for an average-sized adult.


Isotretinoin (1 mg/kg/day for 20 weeks) may be effective in selected cases. The response is variable and unpredictable and complete suppression or prolonged remission is uncommon. Early cases with only inflammatory cystic lesions in which undermining sinus tracts.


Surgical excision is at times the only solution. Residual lesions, particularly indolent sinus tracts, are a source of recurrent inflammation. Local excision is often followed by recurrence. Wide excision of affected skin, and healing by granulation or applying split skin grafts or transposed or pedicle flaps, affords better control. Local recurrence after wide excision varies greatly with the disease site.