Follicular Occlusion Diseases

Table 6.1. Follicular occlusion diseases

Hidradenitis suppurativa

Acne vulgaris (AV)

Acne conglobata (AC)

Dissecting cellulitis of the scalp or perifolliculitis capitis abscedens et suffodiens

Pilonidal cyst

The term follicular occlusion disease refers to a possible common pathogenic mechanism of occlusion of sebaceous or apocrine glands, and diseases included in this term are listed in Table 6.1. An association of these disorders has been described in several patients, suggesting that a causal relationship may be found rather than mere co-occurrence. It has therefore been suggested that the association of HS, acne conglo-bata (AC) and dissecting folliculitis of the scalp should be named follicular occlusion triad. Acne tetrad includes pilonidal cyst in addition to the three aforementioned components. The actual evidence in favour of such aggregation is however predominantly morphological.

Epidemiological studies raise doubt about the general value of these observations (see Chap. 8). They have failed to support it and clinical experience also suggests that these diseases are not generally associated with HS. Acne vul-garis (AV) appears to be uncommon in HS patients, and while patients may display AC, clinical experience suggests that the two diseases are separate as they react very differently to therapy. The epidemiology of these diseases is also different. The age and sex distribution differ con-

siderably between AV and HS, while the other diseases are both much more rare and less investigated. HS is more common in older persons and women, while AV is more common in younger men. Similarly, Propionibacterium acnes and seborrhoea, which are central factors in the development of acne, do not appear to be prominent in HS. In relation to the pilonidal cyst, the abundance of hairs found in these cysts and their solitary and restricted distribution are obvious differences not only between HS and pilonidal cysts, but also between pilonidal cysts and various forms of acne.

The diseases included in the acne triad/tetrad have many similarities, but also profound differences. Our current understanding of the pathogenesis of these diseases, their topographical distribution and their clinical responses to treatment (see Table 6.2) all point towards differences, while the epidemiology points towards significant differences. Therefore, occasional association may well be due to co-occurrence rather than a truly common pathogenic mechanism or a gene linkage.

Table 6.2. Treatment options in follicular occlusive diseases. (? Unknown utility, - not useful, +a useful in selected cases, + useful, ++ somewhat useful, +++ very useful)

Surgery

Retinoids

Tetracyclines and macrolide antibiotics

Immunosuppression

Hidradenitis suppurativa

+++

+a

++

++

Acne vulgaris

+a

+++

+++

+a

Acne conglobata

+

+++

++

Pilonidal cyst +++

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