1. Hidradenitis Suppurativum
Nigel A. Scott MD FRCS
Royal Preston Hospital

2. 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”

3. 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.

4. 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

5. Hidradenitis Suppurativum
Apocrine

6. Hidradenitis Suppurativum
[not Apocrine]

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

8. 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

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

10. 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

11. 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.

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

13. Hidradenitis Suppurativum

15. 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

16. Hidradenitis
2-4% population
4F:1M

17. 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);

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

19. CO2 Laser
J Amer Acad Derm 2002:47:

20. 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:

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

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

23. Genitofemoral
– wide local excision & secondary healing

24. Genitofemoral
– wide local excision & secondary healing

25. Genitofemoral
– wide local excision & secondary healing

26. Genitofemoral
– wide local excision & secondary healing

27. Perianal Hidradenitis

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

29. 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

30. Anal Canal & Hidradenitis
Crohns
Cryptoglandular
Hidradenitis

31. Hidradenitis –surgical options
Perianal Disease – differential diagnosis

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

34. Perianal Hidradenitis
– wide local excision & secondary healing

35. Perianal Hidradenitis
– wide local excision & secondary healing

36. Perianal Hidradenitis
– wide local excision & secondary healing

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

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

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

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

41. 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

42. 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."