We diagnosed hidradenitis suppurativa, a disorder of the terminal follicular epithelium in the apocrine gland–bearing skin. It causes chronic relapsing inflammation with mucopurulent discharge. As seen in this case, it can lead to sinus tracts, draining fistulas, and progressive scarring. It is called acne inversa because it involves intertriginous localizations and not the regions affected by acne (face and back). The most common presentation is painful, tender, firm, nodular lesions in axillae. This patient had very little axillary involvement, but the diagnosis was still hidradenitis. Both obesity and smoking make the condition worse.
Hidradenitis suppurativa can cause disabling pain and social isolation. The patient was desperate for relief. She chose to have intralesional steroid injections for the 3 most painful nodules. We injected the nodules with 10 mg/cc triamcinolone and started the patient on doxycycline 100 mg bid. We stressed the importance of smoking cessation, but the patient did not think she could quit.
Two months later, the patient was still miserable, with multiple tender nodules between and under her breasts. We discussed the options of isotretinoin or surgery; she elected to receive a plastic surgery referral. Six months later the patient returned to the office with new painful nodules in the same area but now adjacent to the large surgical scars. Unfortunately, we still lack a good, long-lasting treatment for severe cases of hidradenitis suppurativa.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R. Hidradenitis suppurativa. In: Usatine R, Smith M, Mayeaux EJ, Chumley H, Tysinger J, eds. The Color Atlas of Family Medicine. New York, NY: McGraw-Hill; 2009:457-460.
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