Slade 2003 - BJPS - Hidradenitis suppurativa

Summary

Hidradenitis suppurativa (HS) is a chronic, recurring inflammatory skin disease characterized by painful, deep-seated nodules and abscesses that rupture and lead to sinus tract formation and scarring. It most commonly affects apocrine gland-bearing areas like the axillae, groin, and anogenital region.

Pathogenesis: HS was previously thought to originate from obstruction of apocrine ducts, leading to the term "apocrinitis." However, recent evidence shows HS begins with follicular occlusion by keratinized stratified squamous epithelium, leading to rupture and spillage of follicular contents into surrounding tissue. This triggers inflammation, abscess formation, and destruction of hair follicles and nearby adnexal structures like apocrine glands. Sinus tracts likely form from ruptured follicular epithelium.

Epidemiology: HS has a prevalence of 0.3-4%. It predominantly affects women at a 3:1 ratio, with peak incidence in the second and third decades of life. Obesity and smoking are associated risk factors. There is likely a genetic component, with autosomal dominant inheritance. HS severity often fluctuates with hormonal changes.

Management: Treatment should be tailored to disease severity and patient factors. Lifestyle modifications like weight loss and smoking cessation may help control mild disease. Topical or systemic antibiotics can treat inflammatory lesions but recurrence after discontinuation is common. Anti-androgens may benefit some women but safety concerns exist with long-term use. Retinoids like acetretin have moderate efficacy. Intralesional steroids provide localized control. Radiotherapy shows promise but requires more study.

For severe HS, radical wide excision of all apocrine-bearing skin is definitive treatment. This often necessitates extensive tissue removal, resulting in large complex defects requiring reconstruction with skin grafts, healing by secondary intention, or flaps. Recurrence risk correlates with adequacy of excision rather than specific reconstruction method. Meticulous excisional technique guided by intraoperative mapping of sinus tract extent is critical. Laser ablation is emerging as less invasive surgical option but pain and healing time may still be significant.

Early diagnosis, multi-disciplinary collaboration, and properly-timed aggressive surgery offer best outcomes. Patients should be warned that surgery does not cure HS but rather controls disease progression. Recurrence is common even with optimal treatment. Frequent complications include scarring, contractures, fistulas, anemia, amyloidosis, arthritis, and rarely squamous cell carcinoma. HS carries substantial physical and psychological burden for patients.

In summary, HS is a chronic debilitating disease originating from follicular occlusion that afflicts apocrine-gland bearing areas. Hormonal factors and genetics likely contribute to pathogenesis. Medical therapies provide limited disease control. For advanced HS, radical wide excision of all involved skin provides definitive treatment but may cause significant morbidity. Early diagnosis and collaborative multi-modal management incorporating lifestyle changes, medications, and properly-planned surgery offer best outcomes in this challenging disease.