Hidradenitis Suppurativa

This is a chronic inflammatory disease occurring on skin containing apocrine glands. It is commoner in women and occurs in the anogenital area as well as the axillae, breasts, thighs, and buttocks. It is a problem of follicular occlusion with the consequent complications of obstruction to the outflow of other apocrine and sometimes sebaceous glands (18). It can be associated with similar conditions such as conglobate acne and pilonidal sinus. Bacteria play a secondary but important role, in the inflammatory process that results leads to scarring and sinus formation. The onset of the disease is after puberty, suggesting that there is a hormonal influence. The skin lesions include comedones often with two pores (bridged comedones), pustules, tender dermal nodules, abscesses, and linear sinus tracks (Fig. 12A and B). Lesions can ulcerate and there is often a persistent purulent discharge. There may also be the complications of episodic cellulitis, fistula formation to the bladder and rectum, and on very long-standing disease, squamous cell carcinoma (SCC). The important differential diagnosis is Crohn's disease but there have been examples of hidradenitis suppurativa and Crohn's disease coexisting (19,20).

Treatment: Weight reduction is important, as well as antiseptic washes. Acute episodes are treated with antibiotics depending on the results of cultures of the skin lesions. Long-term antibiotic treatment with tetracyclines or erythromycin may help

Table 5 Chronic Vulvar Purpura

Clinical

Differential

Diagnosis

Symptoms appearance

diagnosis

Therapy

Chronic vulvar

Itch or burning Ecchymotic

Lichen planus

Topical lidocaine if

purpura

patches in

symptomatic,

vestibule

barrier ointments

Hidradenitis Suppurativa

Figure 11 Crohn's disease. (A) Bilateral edema of the labia majora with vesicle-like lymphangiectasia. (B) (See color insert) Inner aspect of vulva in Figure 9 showing lymphangiectasia. (C) Granulomatous inflammation with non-necrotizing granulomas is the characteristic finding, although sometimes hard to identify.

Figure 11 Crohn's disease. (A) Bilateral edema of the labia majora with vesicle-like lymphangiectasia. (B) (See color insert) Inner aspect of vulva in Figure 9 showing lymphangiectasia. (C) Granulomatous inflammation with non-necrotizing granulomas is the characteristic finding, although sometimes hard to identify.

in milder forms. Oral retinoids have had some success but they require prolonged courses and because of their teratogenicity they cannot be used in women who are planning to have children. Surgery is the best option in severe cases refractory to all medical treatment (Table 7).

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