Chronic vulvar symptoms and dermatologic disruptions: How to make the correct diagnosis

Physical examination reveals fluctuant nodules, scars, and draining sinus tracts of the hair-bearing vulva and crural crease ( FIGURE 5 ). The axillae are clear.

Diagnosis: Hidradenitis suppurativa.

Treatment: The patient begins taking minocycline 100 mg twice daily. Because she is a smoker, you refer her to an aggressive primary care provider for smoking cessation and weight loss management.

Three months later, the patient is developing only about two nodules a month, managed by early intralesional injections of triamcinolone acetonide.

Hidradenitis suppurativa is sometimes called inverse acne because the underlying pathogenesis is similar to cystic acne. Follicular plugging with keratin debris occurs, with additional keratin, sebaceous material, and normal skin bacteria trapped below the occlusion and distending the follicle. As the follicle wall stretches, thins, and allows for leakage of keratin debris into surrounding dermis, a brisk foreign-body response ­produces a noninfectious abscess.

Hidradenitis suppurativa affects more than 2% of the population. ¹² It appears only in areas of the body that contain apocrine glands and in individuals who have double- or triple-outlet follicles that predispose them to follicular occlusion. Therefore, this disease has a genetic component.

Other risk factors include male sex, African genetic background, obesity, and smoking. The prevalence of metabolic syndrome is significantly higher in individuals with hidradenitis suppurativa than in the general population. ¹³

Recommended management
Treatments include:

• chronic antibiotics with nonspecific anti-inflammatory activity (tetracyclines, erythromycin, clindamycin, and trimethoprim-sulfamethoxazole)
• intralesional injection of corticosteroids for early nodules (which often aborts their development)
• TNF alpha blockers (etanercept, adalimumab, infliximab) ^14–16
• surgical removal of affected skin —the definitive therapy.

Note, however, that anogenital hidradenitis often is too extensive for surgery to be practical. In patients who have localized hidradenitis, primary excision is an excellent early therapy, provided the patient is advised that recurrence may occur in apocrine-containing nearby skin. Aggressive curettage of the roof of the cysts has been performed by some clinicians with good response.

Don’t overlook adjuvant approaches
Smoking cessation and weight loss often are useful.

Other therapies backed by anecdotal evidence include oral contraceptives or spironolactone for their anti-androgen effect, as well as metformin, a more recently studied agent.

Local care with antibacterial soaps and topical antibiotics may be useful for some women.

MORE CASES TO COME
In Part 2 of this series, which will appear in the June 2014 issue of OBG Management , we will discuss the following cases:

• atrophic vagina and atrophic vaginitis
• contact dermatitis
• vulvar aphthae
• desquamative inflammatory vaginitis
• psoriasis.

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