Hidradenitis suppurativa is a chronic,
relapsing (recurring), suppurative (pus
forming), cicatrizing (heals with severe
scar formation) disease occurring in the
apocrine (special sweat glands) follicles.

The disease tends to become chronic
and
indolent because of subcutaneous (below
the skin) extension leading to induration
(hardening of tissue), sinus, and fistula
formation.
Hidradenitis suppurativa occurs more commonly in women in their 30's.  The disease
is found more commonly in the white and the black populations and is rarely
observed in the Asian population.

Hidradenitis suppurative is found is commonly found in the
axillary (under arm) and
groin
areas on the body.

What Causes Hidradenitis?
The exact cause of hidradenitis suppurativa has not been determined, although the
following theories have been proposed:

  • Folliculitis (infection or inflammation of hair follicles) is observed in all patients
    with hidradenitis suppurativa; whether this is coincidental or causative has
    not been established.

  • Hormonal theory: Improvement and relapse after pregnancy and
    contraceptive pill intake suggest that low levels of estrogens cause a
    predisposition for hidradenitis suppurativa.

  • Cigarette smoking and lithium therapy have been identified as triggering
    factors for the disease.

What Are the Non-Surgical Treatments Available?
Treatment depends upon the stage of the disease. Initially patients are usually
treated by medical therapy, whereas the patient with long-standing indolent
disease that is no longer responding well to medications often requires surgical
therapy.

Acute-stage treatment options
  • Antibiotics: A short course of antibiotics for a period of 2 weeks is usually
    advisable. The antibiotics used include a combination of erythromycin and
    metronidazole, minocycline, or clindamycin. Cephalosporins and penicillins can
    also be used.

  • Intralesional steroids: Intralesional injection of steroids (eg, triamcinolone 5-
    10 mg diluted with water) can cause the early lesions to involute within 12-24
    hours.

Chronic relapsing–stage treatment options
  • 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. However, the efficacy of the antibiotics may be lost after
    long-term use. Efficacy can usually be regained by stopping the drug for a
    month and restarting it.

  • High-dose systemic steroids (eg, prednisolone 60 mg/d) are useful as
    adjuvants to antibiotics, and they act by reducing the inflammatory process.

  • 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. Etretinate,
    at a dose of 0.5 mg/kg/d for a period of 6 months, is used for patients whose
    conditions are unresponsive to isotretinoin. Retinoids are teratogenic, and
    pregnancy is prevented by the use of contraception. Approximately 40% of
    patients show good response to retinoids.

  • Other therapeutic agents that have been used with limited success include
    cisplatin, methotrexate, 5-alpha reductase inhibitors, and TNF-alpha inhibitors.
    Infliximab has been used in patients having Crohn disease and associated
    hidradenitis suppurativa.

When Should I Consider Surgery?
Recurrent abscess formation, formation of chronic sinus tracts with recurrence and
unresponsiveness to medications are the usual indications for surgery.
Surgery is usually a last resort because of the chronic nature of the condition.   The
disease can be divided into the following 3 clinical stages:

  • Stage 1: Single or multiple abscesses form, without sinus tracts and without
    cicatrization (scar tissue formation).

  • Stage 2: Recurrent abscesses form, with tract formation and cicatrisation (scar
    tissue formation). There may be single or multiple widely separated lesions.

  • Stage 3: Diffuse or near-diffuse involvement or multiple interconnected tracts
    and abscesses are observed across the entire area.

What Happens After Surgery?
  • Regular and prolonged use of postoperative dressings is necessary to aid
    secondary healing.

  • Patients can develop general complications such as pneumonia, deep venous
    thrombosis (DVT), and infection. Active physiotherapy, breathing exercises,
    and early ambulation are encouraged.

  • Postoperative complications specific to the procedure include wound
    breakdown, hematoma formation, wound infection, and graft rejection and
    failure.

  • The overall complication rate is 17-20%.
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