eMedicine Specialties > Emergency Medicine > Dermatology
Hidradenitis Suppurativa
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:
- Crohn disease
- Irritable bowel syndrome
- Down syndrome
- Certain forms of arthritis
- Graves disease or Hashimoto thyroiditis
- Sjögren syndrome
- Herpes simplex
Differential Diagnoses
Candidiasis
Cellulitis
Erysipelas
Other Problems to Be Considered
Bacterial folliculitis and furunculosis
Granuloma inguinale
Lymphogranuloma venereum
Pilonidal cysts
Tuberculous inflammation of the skin
Carbuncle
Epidermoid or dermoid cyst
Workup
Laboratory Studies
- Culture of any exudate obtained (if aspiration or drainage of larger nodules is necessary) will yield a variety of saprophytic and pathogenic bacteria with a preponderance of staphylococci and streptococci.
- Thyroid function studies may be useful if clinically indicated because an association with Graves disease or Hashimoto thyroiditis may occasionally occur.
- If a patient appears toxic or is febrile, laboratory tests should include the following:
- CBC
- Blood cultures
- Culture of exudate
- Routine chemistries
Procedures
- Incision and drainage may be helpful for large, painful, fluctuant nodules that have not opened spontaneously.
- Most nodules will resolve even without drainage.
Treatment
Emergency Department Care
- The nodules of hidradenitis suppurativa may need to be drained in the emergency department, particularly if they are very large, fluctuant, and painful.
- Antibiotics are indicated if cellulitis or fever is present, and the patient should be admitted if he or she appears to be toxic.
Consultations
- General surgery
- Surgical consultation may be obtained for removal of sinus tracts, curettage, and exteriorization of the gland.
- Excision and skin grafting may be helpful for severe intractable cases. Also, surgery should be considered in early cases because the area to excise is smaller and less damaged from recurrences.
- The CO2 laser has been used to strip away glandular tissue. Healing is by secondary intention.
- Radiation treatment has also been used for this condition.
Medication
Tetracycline and erythromycin may be helpful on a long-term basis, and cephalosporins often will help in acute cellulitis. On a short-term basis in the emergency department, dicloxacillin is considered a good choice. However, consideration must be given to using a sulfonamide or clindamycin antibiotic because of the growing presence of methicillin-resistant Staphylococcus aureus (MRSA) for both short-term and long-term treatment. Topical products, such as benzoyl peroxide, may be helpful. Topical and intralesional injections of corticosteroids are sometimes helpful.
Topical clindamycin cream has also been used with some success. Retin-A has rarely been found to be helpful in some patients. Systemic retinoids (Accutane) can reduce the severity of attacks in some patients but is not a reliable cure for hidradenitis suppurativa. Accutane cannot be prescribed in the emergency department due to requirements set forth by the pharmaceutical company. Hormonal manipulation (eg, certain oral contraceptives) has been useful for some patients but is unlikely to be prescribed from the emergency department.
Antibiotics
Therapy must cover all likely pathogens in the context of the clinical setting. In recurrent disease, antibiotics may be administered for 2 or more months.
Tetracycline (Sumycin)
Treats susceptible bacterial infections of both gram-positive and gram-negative organisms as well as mycoplasmal, chlamydial, and rickettsial infections.
Dosing
Adult
250 mg PO qid or 500 mg PO tid
Pediatric
Condition not seen in children
Interactions
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Contraindications
Documented hypersensitivity; severe hepatic dysfunction
Precautions
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Minocycline (Minocin, Dynacin)
For the treatment of infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible Rickettsia, Chlamydia, and Mycoplasma.
Dosing
Adult
100 mg PO bid
Pediatric
Condition not seen in children
Interactions
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Contraindications
Documented hypersensitivity; severe hepatic dysfunction
Precautions
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines; hepatitis or lupuslike syndromes may occur
Dicloxacillin (Dynapen, Dycill)
Binds to one or more penicillin-binding proteins, which, in turn, inhibit synthesis of bacterial cell walls. For treatment of infections caused by penicillinase-producing staphylococci. May use to initiate therapy when staphylococcal infection is suspected.
Resistance to this drug results from alterations in penicillin-binding proteins.
Dosing
Adult
125-500 mg PO qid 1-2 h ac or 2 h pc for 7-10 d
Pediatric
Condition not seen in children
Interactions
Decreases efficacy of oral contraceptives; may decrease effects of anticoagulants; probenecid and disulfiram may increase penicillin levels
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Monitor PT in patients taking anticoagulant medications; toxicity may increase in patients with renal impairment
Sulfamethoxazole and trimethoprim (Bactrim DS, Septra DS)
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.
Dosing
Adult
160 mg TMP/800 mg SMZ PO q12h for 10-14 d
Pediatric
Condition not seen in children
Interactions
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Contraindications
Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Do not use during last trimester of pregnancy because of potential toxicity to newborn (eg, jaundice, hemolytic anemia, kernicterus)
Dosage adjustments (adult adjustments)
CrCl (mL/min) 80-50: Recommended IV dose q18h
CrCl 50-10: Recommended IV dose q24h
CrCl <10: Not recommended
HD: 4-5 mg/kg after HD
During peritoneal dialysis: 0.16-0.8 g q48h
Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBCs frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholics, elderly, those receiving anticonvulsant therapy, those with malabsorption syndrome); hemolysis may occur in G-6-PD deficient individuals; AIDS patients may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation
Erythromycin (E-Mycin, Ery-Tab, E.E.S.)
Recommended dosing schedule of erythromycin may result in GI upset, causing one to prescribe an alternative macrolide or change to tid dosing. Covers most potential etiologic agents, including Mycoplasma species.
Erythromycin is less active against H influenzae. Although 10 d seems to be a standard course of treatment, treating until the patient has been afebrile for 3-5 d seems a more rational approach. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections.
Has the added advantage of being a good anti-inflammatory agent by inhibiting migration of polymorphonuclear leukocytes.
Dosing
Adult
250 mg erythromycin stearate/base (or 400 mg ethylsuccinate) q6h PO 1 h ac, or 500 mg q12h.
Alternatively, 333 mg PO q8h; increase to 4 g/d depending on severity of infection
Pediatric
Condition not seen in children
Interactions
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin, increases risk of rhabdomyolysis; decreases metabolism of repaglinide, thus increasing serum levels and effects
Contraindications
Documented hypersensitivity; hepatic impairment
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI side effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
Clindamycin (Cleocin)
Semisynthetic antibiotic produced by 7(S)-chloro-substitution of 7(R)-hydroxyl group of parent compound lincomycin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Widely distributes in the body without penetration of CNS. Protein bound and excreted by liver and kidneys.
Used for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci).
Dosing
Adult
150-300 mg/dose PO q6-8h; not to exceed 1.8 g/d; alternatively, 600 mg IV divided q8h, depending on degree of infection; not to exceed 4.8 g/d
Topical: Apply 2% lotion sparingly over affected area
Pediatric
Condition not seen in children
Interactions
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Contraindications
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile
Topical dosage form is for external use only, avoid contact with eyes (in event of accidental contact with eye, rinse with copious amounts of cool tap water)
Retinoids
These agents inhibit sebaceous gland function and keratinization.
Isotretinoin (Accutane)
Decreases sebaceous gland size and sebum production; may also inhibit sebaceous gland differentiation and abnormal keratinization.
Dosing
Adult
40-60 mg/d PO for 4 mo
Pediatric
Condition not seen in children
Interactions
Toxicity may occur with vitamin A coadministration; pseudotumor cerebri or papilledema may occur when coadministered with tetracyclines; isotretinoin may reduce plasma levels of carbamazepine
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
May decrease night vision; inflammatory bowel disease may occur; may be associated with development of hepatitis; occasional exaggerated healing response of acne lesions (excessive granulation with crusting) may occur
Diabetes patients may experience problems in controlling their blood sugar level while on isotretinoin; avoid exposure to UV light or sunlight until tolerance achieved; discontinue treatment if rectal bleeding, abdominal pain, or severe diarrhea occur
Mood swings or depression may occur; caution if history of depression
Corticosteroids
These agents modify the body's immune response to a variety of stimuli. Intralesional injections have been used in addition to the cream.
Triamcinolone (Aristocort)
Treats inflammatory dermatosis responsive to steroids; decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability.
Dosing
Adult
Apply a thin film bid/tid until favorable response
Pediatric
Condition not seen in children
Interactions
None reported
Contraindications
Documented hypersensitivity; fungal infections
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use in decreased skin circulation; prolonged use, applications over large areas, and use of potent steroids and occlusive dressings may result in systemic absorption; systemic absorption may cause Cushing syndrome, reversible HPA-axis suppression, hyperglycemia, and glycosuria
Follow-up
Further Inpatient Care
- In severe cases, radical excision of the pathologic tissue with split-thickness skin grafts may be indicated.
- Radiation and laser treatments may be considered as well. However, the reason to admit a patient from the emergency department with hidradenitis suppurativa would be due to toxicity or sepsis, so the main treatment would be supportive antibiotics, such as intravenous clindamycin, vancomycin, and piperacillin and tazobactam sodium (Zosyn).
Deterrence/Prevention
- Minimize heat exposure and sweating.3
- Lose weight if overweight.3
- Avoid constrictive clothing and frictional trauma.3
- Avoid underarm antiperspirants and deodorants (this has not been proven to make a difference).
Complications
- Lymphedema due to lymphatic injury from inflammation and scarring
- Contracture formation at the sites of lesions
- Squamous cell carcinoma (may develop in indolent sinus tracts)
- Disseminated infection (rare)
- Restricted limb mobility from scarring
- Urethral/rectal fistula
- Anemia secondary to chronic infection
- Arthritis secondary to inflammatory injury
Prognosis
- Individual lesions usually heal slowly in 10-30 days with or without drainage.
- Recurrences are common.
- Spontaneous complete resolution occurs in rare cases.
- Relentlessly progressive scarring and sinus tracts may occur.
References
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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
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.
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Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
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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
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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
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