Closed comedones ("white heads") are never present in areas of HS. Open comedones ("black heads") are also absent in early disease but may appear in long-lasting HS, usually as double-ended comedones. These may be taken to reflect the distortion and degradation of the dermal architecture caused by the extensive inflammation and scarring of the disease. They are particularly conspicuous in burnt out lesions, presumably when no longer obscured by the active disease (see Fig. 3.10). As in acne conglobata these are tertiary lesions i.e. "tombstone comedones". They are present in 50% of patients . Their prevalence does not appear to be affected by either concurrent acne or a previous history of significant acne .
Fig. 3.10. Comedones, black heads in burnt-out lesions
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