eMedicine Specialties > Emergency Medicine > Dermatology

Hidradenitis Suppurativa

Author: Diana Fite, MD, FACEP, Clinical Assistant Professor, Department of Emergency Medicine, University of Texas Medical School at Houston, Hermann Hospital
Contributor Information and Disclosures

Updated: Mar 4, 2009

Introduction

Background

Hidradenitis suppurativa is an annoying chronic condition characterized by swollen, painful, inflamed lesions in the axillae, groin, and other parts of the body that contain apocrine 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. Velpeau first described the condition in 1839.

Pathophysiology

The condition has classically been thought to occur when apocrine gland outlets become blocked by perspiration or are unable to drain normally because of incomplete gland development. Secretions trapped in the glands force perspiration and bacteria into surrounding tissue, causing subcutaneous induration, inflammation, and infection. However, more recent studies have indicated that hidradenitis suppurativa is caused by follicular occlusion first, which, in turn, occludes the apocrine glands and causes perifolliculitis. Therefore, it is actually a disorder of the terminal follicular epithelium located in the apocrine gland-bearing skin areas, which may better be termed as acne inversa.1

Hidradenitis suppurativa is confined to areas of the body that contain apocrine glands. These areas are the axillae, areola of the nipple, groin, perineum, circumanal, and periumbilical regions.

Often, patients with hidradenitis suppurativa also are afflicted with acne, pilonidal cysts, and chronic scalp folliculitis; thus, giving rise to the term follicular occlusion tetrad.

For further information, see Hidradenitis Suppurativa.

Frequency

United States

The problem is somewhat common, thought to occur in 1-2% of the population, but the precise incidence and prevalence are unknown.

International

A Danish study noted the prevalence of hidradenitis suppurativa to be in 4% of women.2

Mortality/Morbidity

Hidradenitis suppurativa is painful and can be disabling but is rarely fatal, except when it progresses to overwhelming systemic infection in an immunocompromised patient. Extensive disease can prevent patients from performing normal work functions and from engaging in normal social activities. In some patients, especially those with severe disease, the condition creates significant psychological problems, particularly regarding sexual relationships.

Race

Ingrown hairs are a predisposing factor, thus an increased incidence of the disease occurs in patients with tightly curled hair.

Sex

The incidence of hidradenitis suppurativa is greater in females than in males, thought to be in the range of 4:1 or 5:1. Flare-ups have been associated with menses, with a higher incidence in females with shorter cycles and more days of bleeding during the period.3

Age

Hidradenitis suppurativa does not present prior to puberty because the apocrine glands are inactive until triggered by a surge in sex hormones. The condition may be observed in patients of any age after puberty.

Clinical

History

The most common presentation is that of painful, tender, firm, nodular lesions under the arms.

  • The nodules may open and drain pus spontaneously. Nodules will heal slowly, with or without drainage, over 10-30 days.
  • In typical cases, nodules recur at least several times yearly.
  • In severe cases, the patient may suffer a constant succession of new lesions forming as soon as old lesions heal.
  • Excessive heat, perspiration, tight clothing,4 and obesity4 seem to aggravate the condition. Studies also show that cigarette smoking is a precipitator of the condition.
  • Remissions may last months or years.

Physical

  • The patient may present in considerable pain, with multiple red, hard, raised nodules in areas where apocrine glands are concentrated.
  • Affected areas may include the axillae, periareolar, intermammary zones, pubic area, infraumbilical midline, gluteal folds, genitofemoral areas (top of the thighs in genital area), and the perianal region.
  • As suppuration progresses, surrounding cellulitis may be present. Chronic recurrences result in palpable thick sinus tracts under the skin, which may turn into draining fistulas.
  • The patient may present with a chronic condition in which the multiple nodules have coalesced and are surrounded by a fibrous reaction. This results in scarred and unsightly appearance of the area.
  • Hidradenitis suppurativa may resemble recurrent bacterial folliculitis and furunculosis.

Causes

  • A genetic predisposition to hidradenitis suppurativa likely exists, with one study noting that 38% of patients had a relative with hidradenitis.5
  • Excessive perspiration, often observed in athletes and the obese, may contribute to clogging of the apocrine glands.
  • Disease activity may be related to stress and to cigarette smoking.
  • Hidradenitis may be observed as a primary condition without any obvious cause, but it may be observed in association with the following conditions:

More on Hidradenitis Suppurativa

Overview: Hidradenitis Suppurativa
Differential Diagnoses & Workup: Hidradenitis Suppurativa
Treatment & Medication: Hidradenitis Suppurativa
Follow-up: Hidradenitis Suppurativa
References
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References

  1. Sellheyer K, Krahl D. "Hidradenitis suppurativa" is acne inversa! An appeal to (finally) abandon a misnomer. Int J Dermatol. 2005;44(7):535-40. [Medline].

  2. Jemec GB. The symptomatology of hidradenitis suppurativa in women. Br J Dermatol. Sep 1988;119(3):345-50. [Medline].

  3. Shah N. Hidradenitis suppurativa: a treatment challenge. Am Fam Physician. Oct 15 2005;72(8):1547-52. [Medline]. [Full Text].

  4. Slade DE, Powell BW, Mortimer PS. Hidradenitis suppurativa: pathogenesis and management. Br J Plast Surg. 2003;56(5):451-61. [Medline].

  5. von der Werth JM, Williams HC. The natural history of hidradenitis suppurativa. J Eur Acad Dermatol Venereol. Sep 2000;14(5):389-92. [Medline].

  6. Attanoos RL, Appleton MA, Douglas-Jones AG. The pathogenesis of hidradenitis suppurativa: a closer look at apocrine and apoeccrine glands. Br J Dermatol. Aug 1995;133(2):254-8. [Medline].

  7. Chaikin DC, Volz LR, Broderick G. An unusual presentation of hidradenitis suppurativa: case report and review of the literature. Urology. Oct 1994;44(4):606-8. [Medline].

  8. Deroo H, Aelbrecht M, t'Kindt J, Vermander F, De Bersaques J. Hidradenitis suppurativa. Dermatologica. 1990;180(3):193-4. [Medline].

  9. Edlich RF, Silloway KA, Rodeheaver GT. Epidemiology, pathology, and treatment of axillary hidradenitis suppurativa. J Emerg Med. 1986;4(5):369-78. [Medline].

  10. Gee BC, Dawber RP. Hidradenitis suppurativa. J R Soc Med. Dec 2000;93(12):661. [Medline]. [Full Text].

  11. Hughes LE. Pathogenesis, clinical features and management of hidradenitis suppurativa. Ann R Coll Surg Engl. Jul 1997;79(4):309-10. [Medline].

  12. Jemec GB, Heidenheim M, Nielsen NH. Hidradenitis suppurativa--characteristics and consequences. Clin Exp Dermatol. Nov 1996;21(6):419-23. [Medline].

  13. Jemec GB, Heidenheim M, Nielsen NH. The prevalence of hidradenitis suppurativa and its potential precursor lesions. J Am Acad Dermatol. Aug 1996;35(2 Pt 1):191-4. [Medline].

  14. Konig A, Lehmann C, Rompel R. Cigarette smoking as a triggering factor of hidradenitis suppurativa. Dermatology. 1999;198(3):261-4. [Medline].

  15. Leitch DN, Holland CD, Langtry JA. Hidradenitis suppurativa and monoarthritis of the hip [letter]. Clin Exp Dermatol. Jul 1997;22(4):206-7. [Medline].

  16. Paletta C, Jurkiewicz MJ. Hidradenitis suppurativa. Clin Plast Surg. Apr 1987;14(2):383-90. [Medline].

  17. Parks RW, Parks TG. Pathogenesis, clinical features and management of hidradenitis suppurativa. Ann R Coll Surg Engl. Mar 1997;79(2):83-9. [Medline].

  18. Radcliffe KW. Hidradenitis suppurativa. Genitourin Med. Feb 1991;67(1):58. [Medline].

  19. Rayner CR. Pathogenesis, clinical features and management of hidradenitis suppurativa. Ann R Coll Surg Engl. Jul 1997;79(4):309. [Medline].

  20. Rorison P, Ghosh M. Pathogenesis, clinical features and management of hidradenitis suppurativa. Ann R Coll Surg Engl. Sep 1997;79(5):385. [Medline].

  21. Thomas R, Barnhill D, Bibro M. Hidradenitis suppurativa: a case presentation and review of the literature. Obstet Gynecol. Oct 1985;66(4):592-5. [Medline].

  22. Watson JD. Hidradenitis suppurativa--a clinical review. Br J Plast Surg. Oct 1985;38(4):567-9. [Medline].

  23. Williams ST, Busby RC, DeMuth RJ. Perineal hidradenitis suppurativa: presentation of two unusual complications and a review. Ann Plast Surg. May 1991;26(5):456-62. [Medline].

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Further Reading

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Keywords

hidradenitis suppurativa, acne inversa, follicular occlusion, acne, pilonidal cysts, chronic scalp folliculitis, spiradenitis, apocrine glands, sweat glands, chronic acneiform infection, nodular lesions, cellulitis, excessive perspiration, Crohn disease, irritablebowel syndrome, Down syndrome, arthritis, Graves disease, Hashimoto thyroiditis, Sjögren syndrome, herpes simplex, Crohn's disease, Sjögren's syndrome

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Contributor Information and Disclosures

Author

Diana Fite, MD, FACEP, Clinical Assistant Professor, Department of Emergency Medicine, University of Texas Medical School at Houston, Hermann Hospital
Diana Fite, MD, FACEP is a member of the following medical societies: American Association of Women Emergency Physicians, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, and Texas Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Robert M McNamara, MD, FAAEM, Chair and Professor, Department of Emergency Medicine, Temple University School of Medicine
Robert M McNamara, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Pennsylvania Medical Society, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Mark W Fourre, MD, Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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