A CASE OF A CASE OF RECURRENT RECURRENT FOLLICULITISFOLLICULITIS

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• 47 year

• Male patient

• Ex-serviceman

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Presenting complaints• Multiple red raised purulent

discharging lesions over the groin and the buttocks of 2 years duration.

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History of present illness

• Individual had initially developed two red raised lesions over the right gluteal region, which progressed over a span of 2 months, to involve the whole of the gluteal regions, perineum and the groin.

• He had been diagnosed as a case of multiple folliculitis and managed with a course of antibiotics at various centres.

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On examination• Vitals and systemic examination-

NAD• Dermatological examination

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Differential Diagnoses• Abscess• Carbuncles• Furunculosis• Infected or inflamed epidermal cysts• Lymphogranuloma venereum• Scrofuloderma• Actinomycosis• Pilonidal cyst • Cutaneous manifestation of Crohn's disease• Hidradenitis suppurativa

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Diagnoses

• Hidradenitis suppurativa

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Diagnostic criteria relies on the presence of:

• Typical lesions, specifically deep-seated painful nodules: 'blind boils' in early lesions; abscesses, draining sinus, bridged scars and 'tombstone' open comedones in secondary lesions

• Typical topography, specifically, axillae, groin, perineal and perianal region, buttocks, infra- and inter-mammary folds

• Chronicity and recurrences.

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Investigations• Relevant haematological and

biochemical parameters were normal

• Lipid profile-Normal• VDRL-NR• HBSAg-Negative

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Final diagnoses• Hidradenitis suppurativa

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Treatment• Cap Isotretinoin 20 mg OD X 2

weeks 20 mg BD X

10weeks

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HIDRADENITIS HIDRADENITIS SUPPURATIVASUPPURATIVA

DISCUSSIONDISCUSSION

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• Hidradenitis suppurativa (HS) is a disorder of the terminal follicular epithelium in the apocrine gland–bearing skin.

• Characterized by– comedolike follicular occlusion– chronic relapsing inflammation– mucopurulent discharge– progressive scarring.

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Pathophysiology• Disorder of the apocrine glands • Frequent association with acne• Dissecting cellulitis of the scalp and

neck, and acne conglobata commonly occur in the same patient

• central pathogenetic event - tendency for follicular hyperkeratinization with secondary bacterial infection.

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Epidemiology• 1 % of the general population• Common in blacks• Females> males (2.8:1)

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Diagnosis• Consensus approach - 3 key

elements are required to diagnose HS– Typical lesions– Characteristic distribution– Recurrence.

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Primary lesions• Painful and/or tender erythematous

papules & nodules • Painful or tender abscesses and

inflamed discharging papules or nodules • Dermal contractures and ropelike

elevation of the skin • Double-ended comedones

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Sites• Predilection for the intertriginous regions.

– Axillary and inguinoperineal regions are most commonly affected.

• Other zones – the areola of the breast, the submammary

fold, the periumbilical region, the scalp, the zygomatic and malar areas of the face, the nape of the neck, the external auditory meatus, and the shoulders.

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• Arthritis • SAPHO syndrome• Pyoderma gangrenosum

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• The exact etiology of HS remains obscure.

• Proposed etiologic factors, such as occlusion and bacterial infection, genetics, host defense defects, hormones, cigarette smoking, and irritants, are likely only secondary factors

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Staging

• First stage -solitary or multiple, isolated abscess formation without scarring or sinus tracts.

• Second stage -recurrent abscesses, single or multiple widely separated lesions with sinus tract formation, and cicatrization.

• Third stage -diffuse or broad involvement with multiple interconnected sinus tracts and abscesses.

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Treatment• Medical Care• Initial treatment consists of the

following: – Practicing local hygiene and ordinary

hygiene • Instituting weight reduction in patients who

are obese • Using antiseptic and antiperspirant agents

(eg, 6.25% aluminum chloride hexahydrate in absolute ethanol)

• Applying warm compresses with sodium chloride solution

• Wearing loose-fitting clothing

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• Antibiotics• Retinoids• Dapsone• Hormones• Immunobiologicals• Steroids

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• Surgery– Local incision and drainage of purulent

lesions– Unroofing of sinus tracts and

curettage of fistulous tracts– Removal of the affected area and the

adjacent apocrine glandular zone to 2 cm beyond the diseased portion

– CO2 Laser– Regional excision

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Complications• Sec infection & septicaemia• Sinuses and fistulas• Local destruction of the genitalia• Elephantiasis• Squamous cell ca• Regional mobility restricted

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