ST. Louis -- In the past year, Dr. Sebastian Paro has treated a dozen cases of hidradenitis suppurativa, once considered a relatively rare disease.
And when it strikes, if patients don't respond to antibiotic therapy, don't delay surgery Waiting will only result in having to do more extensive, often disfiguring excisions later on, Dr. Faro, an ob.gyn. and infectious disease expert, said at the 11th International Pelvic Reconstructive and Vaginal Surgery Conference.
The etiology of hidradenitis suppurativa is unknown but appears to involve bacterial infection in the apocrine glands and starts as a single inflamed follicle that spreads secondarily through the sinus tracts.
Medical therapy with antibiotics, steroids, and hormones is often ineffective, leaving surgery with wide excision of the affected area as the only reasonably effective therapeutic approach, said Dr. Faro of the University of Texas, Houston.
"It's very important that we do not confuse [hidradenitis suppurativa] with folliculitis," he said. In the early stages, the two conditions look alike, but the treatment approach to each is very different.
The axilla, buttocks, vulva, and groin are where hidradenitis suppurativa lesions are most commonly found. They characteristically appear as twin comedones forming a single follicle, which causes it to form a Y-like split on the surface. Close inspection reveals a triangle of three blackheads, which is key for distinguishing it from folliculitis.
It's not dear if the inflammatory process is prompted by infection, but in any case, the process seals off the apocrine gland, and bacteria in the gland cause an abscess.
"When you see these draining spontaneously you shouldn't jump forjoy. In fact, it's rather disheartening because they've ruptured at the surface of the nodes, but they've also ruptured subdermally," he said. The disease then spreads from one apocrine gland to another subdermally, and the patients develop subsequent abscesses in adjacent glands, causing the process to continue, Dr. Faro said at the meeting, which was jointly sponsored by the Society of Pelvic Reconstructive Surgeons and Emory University.
Oral antibiotic therapy with broad-spectrum agents such as metronidazole plus ofloxacin or dindamycin plus ofloxacin can be helpful if the disease is caught early; treatment lasts 14-30 days.
Treatment with steroids such as triamcinolone acetonide injection intralesionally or oral prednisone has also been described with some success. Patients have their best shot at a successful outcome with medical therapy when there are only one or two palpable lesions. When the infection spreads to other glands, it's usually too late for medical therapy.
When multiple nodules are present, the patient has a chronic disease process that's been going on for years. Women with multiple nodules usually say that they've had a long history of sores that rupture spontaneously and drain purulent discharge. The discharge smells so bad that they frequently avoid going to the doctor and stay home from work because they can't eradicate the odor even after showering-several times.
When patients are in an active phase of the disease, the area will remain indurated with the subdermal process churning below the surface, They will go through periods of senescence, and then the lesions reoccur seemingly spontaneously.
Key to the surgical approach is outlining where the fistulous tracts lead and excising the involved tissue. This is tricky, because the tracts run along multiple axes and go in multiple directions. If an unroofing technique is used, Dr. Faro recommended taking a ductal probe and finding a lesion that's open and gently inserting the probe into the lesion. "Let the probe find the path of least resistance, and that will be the fistulous tract. We usually outline these so we know what direction they go. We do this in a 360-degree circle to find all the tracts," he said. The lesion is excised, and the tracts are opened and either curated or lasered.
COPYRIGHT 2001 International Medical News Group
COPYRIGHT 2002 Gale Group
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