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Hidradenitis Suppurativa

Hidradenitis suppurativa is a chronic suppurative and scarring disease of the skin and subcutaneous tissue occurring in the armpits, around the genitalia and anus, 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, except for the lack of association with HLA-B27.

Treatment

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 of triamcinolone acetonide (Kenalog, 2.5 to 10 mg/ml).

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 in particular. Oral contraceptives do not seem to work nearly as well.

Antibiotics.

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.

Isotretinoin.

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.

Surgery.

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.