Hidradenitis suppuritiva

A chronic, recurrent, inflammatory skin disorder with chronically draining wounds and sinus tracts

Pathogenesis:

• Commonly thought result from occlusion of apocrine glands or the hair follicular duct
• This results in stasis and dilation followed by bacterial infection
• Glands can rupture into the subcutaneous space, causing abscesses and potentially leading to complex subcutaneous sinuses and draining tracts
• Longstanding inflammation may result in subcutaneous scarring, contractures, and chronic induration of the skin

Presentation

• Chronic boils/folliculitis in intertriginous sites: axillae, inframammary, pubis, inguinal folds, genitalia, gluteal cleft, perianal.
• Perineal disease more commonly seen in men - diagnose based on distribution (can extend onto buttocks, upper thighs, and medially to the dentate line), characteristic subcutaneous 'pit-like' scarring, distorting contractures, and induration of the skin

Staging

• Hurley stage - see below
• Can also use the Sartorius Hidradenitis Suppuritiva score

Treatment

• Medical (overseen by dermatologist):
  • Roaccutane has a role in some patients - seems to work well, but side effects
  • COCP, spironolactone and finasteride have all improved outcomes
  • Immunologic agents
• Surgical:
  • From general surgery POV, focus on Hurley I disease
  • The only operation we would generally offer is I+D for big abscesses separated by normal skin
  • More complex operations may involve deroofing of sinus tracts and local excision of badly affected skin.