Hidradenitis suppurativa

HOUSTON -- Surgery remains the treatment of choice for patients plagued by anogenital hidradenitis suppurativa, Dr. Peter J. Lynch said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

Surgical excision is the only approach that truly eliminates the disorder's painful, inflamed, disfiguring nodules characteristic of this disorder, he said.

Antibiotics are of limited efficacy. Corticosteroids administered systemically for 5-7 days relieve inflammation only temporarily Dermatologists rarely perform this type of surgery, so often the task falls to the gynecologist or gynecologic surgeon.

"It's better to do a narrow excision and leave active disease on the margins than a more extensive procedure because the disease will recur at the surgical site anyway," Dr. Lynch said.

It's important to warn patients that the condition usually recurs, so they'll probably need surgery more than once. The nodules have a significant impact on quality of life because they hurt, rupture, leave scars, rub against clothing, and interfere with sexual intercourse. Most patients are "deliriously happy" to have them removed with surgery and generally are willing to undergo surgery again later if needed, said Dr. Lynch, professor emeritus of dermatology at the University of California, Davis.

Hidradenitis suppurativa occurs in hair follicles above apocrine ducts in the "milk line"--the axillas, breasts, central abdomen, and anogenital area--that become blocked and cannot normally discharge accumulated keratinous and bacterial debris, which builds up until the duct and the follicle rupture and spew it into the surrounding tissue, setting up an inflammatory foreign-body reaction.

The lesions, which are usually 14 cm in diameter, may also appear on the upper inner thighs and over the buttocks. Drainage of purulent material may continue for days or even weeks, and some patients develop regional lymphadenopathy, marked by mild fever, arthralgia, and malaise.

Furunculosis is the differential diagnosis, but in that condition the lesions are isolated and scattered and don't occur in the milk line. When in doubt, look for the diagnostic hallmark of hidradenitis suppurativa: twin comedones in the affected area, the result of an abnormal Y-shaped bifurcation of the follicular outlet.

That bifurcation is one of the factors that makes it difficult for the follicle to dispel its accumulated debris. Heat and sweat retention and friction caused by rubbing of clothing or skin also contribute to the occlusion. Obese women and African Americans seem to be at especially high risk.

Untreated, the lesions may heal but new ones develop, and the condition remains active until scarring eliminates all the involved follicles. In severe cases, frank genital mutilation may occur, he said.

Patients with the disease also frequently have cystic acne, which occurs through an analogous process. Rare cases of squamous cell carcinoma have been associated with long-standing disease.

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