Hidradenitis Suppurativum Nigel A. Scott MD FRCS Royal Preston Hospital

Hidradenitis Suppurativum Greek- hidros=sweat & aden=glands “Painful, inflamed lesions in the axillae, groin, and other parts of the body that contain apocrine glands” “…..painful eruptions and malodorous discharge”

Quality of Life and Hidradenitis J.M. Von Der Werth, G.B.E. Jemec (2001) Morbidity in patients with hidradenitis suppurativa British Journal of Dermatology 144 (4), 809–813.

Hidradenitis Suppurativum “Apocrine” Sweat Glands develop during mid puberty sweat contains fatty materials that are broken down by bacteria – main cause of sweat odour emotional stress increases production of sweat

Hidradenitis Suppurativum Apocrine

Hidradenitis Suppurativum [not Apocrine]

Hidradenitis Suppurativum occlusion of the hair follicle (rather than the apocrine gland) due to a defect in terminal follicular epithelium

Hidradenitis Suppurativum occlusion of the hair follicle (rather than the apocrine gland) due to a defect in terminal follicular epithelium bacteria invade the apocrine system via the hair follicles, become trapped beneath the keratinous plugs, and multiply rapidly in the apocrine sweat

Hidradenitis Suppurativum 3. glands rupture and spread the infection extending the tissue destruction and skin damage

Hidradenitis Suppurativum 3. glands rupture and spread the infection extending the tissue destruction and skin damage 4. bacterial superinfection with streptococci, staphylococci, and coliforms - BUT cultures from lesions are frequently sterile and antibiotics are not curative

Hidradenitis Suppurativum chronic acneiform infection of the cutaneous apocrine glands involves adjacent subcutaneous tissue and fascia hallmark - is sinus tracts (which can become draining fistulas) in the apocrine gland body areas.

Hidradenitis Suppurativum Apocrine Gland distribution axillae periareolar, intermammary pubic area, infraumbilical midline, gluteal folds, genitofemoral areas perianal region.

Hidradenitis Suppurativum

Stage 3 Hidradenitis Suppurativum Stage 1: Single or multiple abscesses form, without sinus tracts and cicatrization Stage 2: Recurrent abscesses with tract formation and cicatrisation - single or multiple widely separated lesions. Stage 3: Diffuse or near- diffuse involvement or multiple interconnected tracts and abscesses are observed across the entire area

Hidradenitis 2-4% population 4F:1M

Gender and disease location Area(s) of involvement Male (n = 15) Female (n = 42) P value Axilla 2 (13%) 37 (88%) <.0001 Unilateral 1 (50) 19 (51) NS Bilateral 18 (49) Inguinoperineal 13 (87%) 5 (12) 1 (8) 4 (80) .0131 12 (92) 1 (20) Axilla and inguinoperineal 1 (7) 3 (8) Kagan et al. Surgical treatment of hidradenitis suppurativa: A 10-year experience Surgery 2005:138(4);734-741

Hidradenitis – medical options topical clindamycin hormonal cyproterone acetate; ethinyloestradiol retinoids infliximab

CO2 Laser J Amer Acad Derm 2002:47:280-285

Hidradenitis –surgical options drainage of sepsis – 100% recurrence laying open of tracks wide local excision +/- skin grafts “The surgical option of choice for late stage HS is wide local excision with healing by secondary intention” Surgical treatment of hidradenitis suppurativa Br J Surg 1992; 79: 863-6.

Hidradenitis –surgical options Axillae – wide local excision & secondary healing

Hidradenitis –surgical options Genitofemoral – wide local excision & secondary healing

Genitofemoral – wide local excision & secondary healing

Genitofemoral – wide local excision & secondary healing

Genitofemoral – wide local excision & secondary healing

Genitofemoral – wide local excision & secondary healing

Perianal Hidradenitis

Hidradenitis –surgical options Perianal Disease – differential diagnosis Crohns disease Cryptoglandular sepsis pilonidal disease tuberculosis, actinomycosis etc

Anal Canal & Hidradenitis the distal two thirds of the skin of the anatomic anal canal contains hair follicles with sebaeceous and apocrine glands hidradenitis supprativum rarely involves the anal canal if it does it tracks subcutaneously and not across the sphincter it never tracks above the dentate line

Anal Canal & Hidradenitis Crohns Cryptoglandular Hidradenitis

Hidradenitis –surgical options Perianal Disease – differential diagnosis

Perianal Hidradenitis drainage of sepsis laying open of tracks wide local excision +/- skin grafts [? colostomy]

Perianal Hidradenitis – wide local excision & secondary healing

Perianal Hidradenitis – wide local excision & secondary healing

Perianal Hidradenitis – wide local excision & secondary healing

Kagan et al. Surgical treatment of hidradenitis suppurativa: A 10-year experience Surgery 2005:138(4);734-741

Kagan et al. Surgical treatment of hidradenitis suppurativa: A 10-year experience Surgery 2005:138(4);734-741

Hidradenitis – surgical outcomes Ritz et al Extent of surgery and recurrence rate of hidradenitis suppurativa Int J Colorectal Dis 1998;13:164-168. 31 patients 6F:23M mean age 31yrs surgery 6 abscess drained 14 limited excision, 2 suture 11 wide local excision

Ritz et al Extent of surgery and recurrence rate of hidradenitis suppurativa Int J Colorectal Dis 1998;13:164-168. Drainage Local Excision & Suture WLE

Hidradenitis Suppurativum Summary common cause of serious morbidity 1-4%; 4F:1M occlusion of the hair follicle (rather than the apocrine gland) due to a defect in terminal follicular epithelium axilla/ inguinogenital, perianal Stage 3: Diffuse or near- diffuse involvement or multiple interconnected tracts and abscesses are observed across the entire area medical - topical clindamycin, oral contraceptive perianal – differential diagnosis wide local excision best results with or without mesh skin graft

The DoH said: "The department has accepted the need for change and the revised approach will now be tested with junior doctors, selectors, deanery recruitment teams and employers."