Management of Severe Hidradenitis Suppurativa

Abstract

Hidradenitis suppurativa (HS) is a devastating and disfiguring disease of the skin involving the terminal follicular epithelium within the apocrine-gland-bearing skin. We present an interesting case of a 58-year-old female who presented with a 10-year history of refractory HS of the gluteal, perineal, perianal, and groin region. She had been chronically treated with multiple antibiotics in the past with no improvement. The patient subsequently underwent surgical local excision with complex closure. Medical management alone may not be optimal, especially in refractory disease. Early and aggressive surgical intervention and interdisciplinary approach are needed for patients with chronic and advanced stage of HS.

Keywords: anal fistula; crohn’s disease; hidradenitis suppurativa; verneuil’s disease.

Figure 1. Preoperative image of the external genitalia of a comparable case. Marked scarring and fistulous tracts were evident in the pubis, vulva, and groin.

Figure 2. Postoperative image of a comparable case. Patient underwent modified radical vulvectomy, excision of left perianal HS, and advancement skin flap closure.

HS, hidradenitis suppurativa

Figure 3. Histopathology of HS (hematoxylin-eosin, original magnification ×4). (a) Hair follicle with desquamated keratin, surrounded by dense inflammatory infiltrates; (b) suppuration may extend into the adjacent connective tissue, where there may be a foreign body-type reaction of histiocytes and giant cells due to the keratin.

HS, hidradenitis suppurativa

Figure 4. Histopathology of HS (hematoxylin-eosin, original magnifications ×2). (a) Sinus tract with heavy neutrophilic or mixed inflammatory infiltrate; (b) marked suppuration and frank abscess formation.