Case Presentation #1 Madison Zuis Nur 680

Client and Source of Encounter Name= M.M. Age = 24 years Gender= female Reason for visit= annual GYN physical Setting = North Country OB/GYN, Glens Falls, NY

History of Present Illness Presents to office for annual GYN physical and PAP No GYN complaints No recent illness Seen in ER last week for “ingrown hair” in pubic region and treated with Doxyclycline 100mg po BID Finished antibiotics yesterday, area still red and swollen New “ingrown hair” appeared two days ago under left axilla

Review of Systems General- Thinks she had a fever in ER. Denies chills, malaise, night sweats, appetite changes or weight gain. Respiratory- Denies pain, dyspnea, orthopnea, wheezing, cough, sputum, hemoptysis, night sweats, asthma, bronchitis, exposure to TB Cardiac- Denies heart murmurs, pain or palpitations, dyspnea, or edema. Musculoskeletal- Denies pain. Denies gout, muscle pain, redness, tenderness. Skin- Reports redness and warmth to left groin, pus-like drainage from ingrown hair. Left axilla tender + warm, no open areas. Genital/Rectal-. Mons pubis without lesions/rash. Scarce pubic hair present. Labia minora pink, no erythema, matches skin tone. Perineum nontender, without lesions. Labia majora without lesion or discharge. Clitoris, midline. Urinary meatus pink, no discharge. Vaginal opening pink and dry. Bartholins glands smooth, pink, non tender. Cervix pink, symmetrical, smooth, and firm. Positioning midline. Small cervical os. No discharge at introitus; no lesions appreciated. Uterus palpable, nontender. Rectum pink, free of discharge.

Past Medical History Medical Illness Polycystic Ovarian Syndrome( PCOS) Obesity ( BMI 32) Smoker ( 5 cigarettes day) Surgeries I+D 2012 left buttock Allergies NKDA Medications- Multivitamin daily Doxycycline 100mg BID x 7days (completed)

Past Medical History Health Status View herself as healthy Would like to lose weight, started eating breakfast daily Acknowledges need for smoking cessation Health Risks Obesity Little physical activity Smoking Disability None known- works as a house manager at a group home Family Problems Parents divorced, lives with mother; does not care for mothers new boyfriend ( ETOH abuse) Sister is best friend

Family History Mother Obesity, breast CA, PCOS Father Unknown Sister Obesity, depression, anemia Maternal Grandparents Obesity, DM, HTN, MI, breast CA Paternal Grandparents

Differential Diagnosis Catscratch disease Actinomycosis Cutaneous blastomycosis Ersipelas Granuloma Inguinale Hidradenitis Suppurativa ( Medscape, 2014)

Redefining the Diagnosis Cat Scratch disease Tender regional lymphadenopathy Exposure to cats (2-8 weeks) 90% of patients develop one or more 3-5 mm red/brown non tender papules at inoculation site Actinomycosis subacute-to-chronic bacterial infection caused by filamentous, gram-positive, non– acid-fast, anaerobic-to-microaerophilic bacteria Most common cervicofacial ( lumpy jaw). In women- pelvis usually from IUD Lower abdominal discomfort, abnormal vaginal bleeding or discharge (Medscape, 2014)

Redefining the Diagnosis Cutaneous blastomycosis systemic pyogranulomatous infection usually caused by the inhalation of spores (Blastomyces dermatitidis) Flu-like symptoms after exposure purplish-gray verrucous lesions with heaped borders or friable lesions that ulcerate. Ersipelas bacterial skin infection involving the upper dermis that characteristically extends into the superficial cutaneous lymphatics Hx of trauma or recent pharyngitis C/o itching, burning, tenderness (Medscape, 2014)

Redefining the Diagnosis Granuloma Inguinale chronic bacterial infection that frequently is associated with other STDs Large painless ulcers, odor (Medscape, 2014)

Hidradenitis Suppurativa

Chronic, recurrent inflammatory disease characterized by painful subcutaneous nodules Axillae Perineum Inframammary folds ( Li & Barankin, 2011)

Etiology / Incidence Rare, prevalence is thought to be about 1% Typically 2 nd or 3 rd decades develops, onset after menopause is rare, women tend to clear post menopause Mean age of onset is around 23 years No clear racial predilection Black skin, more aprocrine glands ( Topley & Brain 2013) 4xs more common in women than men 1/3 of people with HS have a blood relative with HS (AAD, 2014) (Walls, et al 2010)

Pathophysiology Unknown cause- believed multifactorial Acne-like hyperkeratinistion of the follicular unit Leads to occlusion and rupture Release keratin, sebum, bacteria and hair into dermis Inflammation and necrosis of the sebaceous and/or sweat gland Results in inflammatory process that engulfs the apocrine gland Rupture of overlying skin, fibrosis and sinus tract formation ( Wall, et al 2010)

Signs and Symptoms Early One ( or several) breakouts that look like pimples or boils Clear and reappear Late Painful deep breakouts that heal and reappear Rupture and leak foul smelling fluid Scarring; scarring that becomes thick Spongy-like skin( sinus tract tunneling)’ (AAD, 2014)

Diagnosis Hurley Staging system Stage 1 Single or multiple abscesses without sinus tracts or scarring ( apprx 75% of patients) Stage 2 Single or multiple widely separated abscesses; scarring and/or tract formation ( apprx 24%) Stage 3 Diffuse or near diffuse involvement or multiple interconnected sinus tracts and abscesses across an entire affected region ( apprx. 1%) ( Petrou, 2012)

Treatment Pharmological Antibiotics First line therapy Fair evidence to support the use in an evidence based review of the literature ( Alhusayen & Shear, 2012) PO- tetrecylcines Topical- 1% or 2% clindamycin BID x 3 months Hormone therapy Acutane Estradiol 5omg in combination with norgesterol 500mg (AOCD, 2014) Steroids Tumor necrosis factor-a inhibitors Fair evidence to support the use in Stage II-III; expensive, adverse-effect profile ( Alhusayen & Shear, 2012) Infliximab Etanercept adalimumab (Walls, et al 2014)

Treatment NonPharmological I+D Carbon Dioxide laser therapy Destroys hair follicles, may take multiple treatments, expensive Wide surgical excision ( Stage III) Split thickness skin grafting Wound vac therapy currently being researched, small 5 case study showed success ( Alharbi, et al 2012)

Management/ Patient Education Avoid tight fitting clothes Keep skin cool Weight loss Smoking cessation Stop shaving where breakouts occur Stress management Wound care- packing, drain care, etc Education Not contagious Poor hygiene does not cause HS

Follow up and Referrals Dermatology General surgeon Counseling Body image

M.M. Visit Referral to General Surgeon and Dermatology Start BCPs Ortho-Cyclen 28 po daily Clindamycin 2% cream BID Follow up in 1 month Counseling considered

References Alharbi, Z., Kauczok, J., & Pallua, N. (2012). A review of wide surgical excision of hidradenitis suppurativa, BMC Dermatology, 12(9) Alhusayen, R. & Shear, N. (2012). Pharmacologic Intervention for Hidradenitis Suppurativa, American Journal of Clinical Dermatology, 13(5) American Academy of Dermatology (2014). Hidradenitis suppurativa. Retrieved February 21st, 2015 from a-to-z/disease-and treatments/hirdradenitis-suppurativahttp:// a-to-z/disease-and American Osteopathic College of Dermatology ( 2015). Hidradenitis Suppurativa. RetrievedFebruary 21st, 2015 from Li, K. & Barankin, B. (2011). Dermacase, Canadian Family Practice, 57(9) Medscape (2014). Hidradenitis Suppurativa, retrieved Febrauary 21 st from Petrou, I. (2012). Algorithm provides quicker diagnosis of hidradenitis suppurativa, Dermatology, 12 (3)14-16 Topley, B. & Brain, S. (2013). Hidradenitis suppurativa: a case study, British Journal of Nursing, 22(15) Walls,B., Mohammad, S., Campbell, J., Arcer,L., & Beale, J. (2010). Negative pressure dressing for severe hidradenitis suppurativa (acne inverse): a case study, Journal of Wound Care, 19(10)