Primary Early Lesions

Insidious onset with pruritus, erythema and hyperhidrosis has been reported, but such "prodromes" are most likely rare or not noticeable to the patients. Most frequently, the first lesion is a solitary painful, deep-seated nodule (0.5-2 cm in diameter), in an area of inverse or apocrine-gland-bearing skin such as e.g. the axilla (see Fig. 3.1a, b). This lesion is round and deep without any "pointing" or central necrosis such as occurs in a furunculosis (it forms a "blind boil"). It may resolve spontaneously within several days - a mean of 7 days is described [12] - or persist as a non-tender, "silent" nodule with subsequent recurrences of inflammatory episodes over weeks or even months without any evidence of suppuration.

Usually the lesion will progress to form an abscess which may open superficially to the surface yielding purulent and/or sero-sangui-nous drainage. This abscess may fail to open spontaneously and becomes extremely painful, leading to a surgical drainage (see Fig. 3.2). Drainage typically offers temporary relief, but the disease has a strong tendency to reoccur at exactly the same place. The diagnosis is frequently missed at this stage.

Hidradenitis Suppurativa
Fig. 3.1a,b. a Early nodule; this lesion is not a "typical deep-seated nodule", which is more palpable than visible; it is a more superficial nodule. b Early lesion, inflammation accessible to antibiotic therapy

Clinical Presentation

Fig. 3.2. Incision of an abscess yielding pus

Chronicity and recurrences are the hallmark of HS. Recurrence at the same site, appearance of new lesions in adjacent skin and coalescence of existing lesions by extension will result in secondary lesions. Fibrosis is another hallmark of the secondary lesions. Fibrosis affects the surrounding skin, and the secondary lesions are therefore thought to perpetuate the disease. Histologically the secondary lesions are characterized by the appearance of sinus tracts. Clinically these are persistent for months, or even years, and regularly cause problems to the patient.

This kind of lesion may seem to resolve, only to start draining again after several months of "rest" (see Fig. 3.3). Their potential for resolution is not known, and to the patients they often appear as permanent problems. The sinus tracts are not always palpable, and may only become apparent when an intralesional injection is made and the injected substance appears at a distance from the site of injection.

The draining sinus has a linear or angular shape. At first it is single, then multiple sinus tracts usually appear, with permanent discharge. There is frequently foul odour from Gram-negative colonization (see Fig. 3.4). Because of the chronic inflammation and disruption of the sinus tracts multiple pyogenic granulomas may appear, adding another recognizable feature to the secondary lesions of HS (see Fig. 3.5).

Fig. 3.3. Inguinal hidradenitis suppurativa (HS): nodule, closed sinus, comedones; severity: Hurley's I in a quiet period

Fig. 3.4. More severe case of inguinal HS with nodules, fistulas, hypertrophic scarring. Severity: Hurley's II-III

Fig. 3.5. Pyogenic granulomas sprouting from HS sinuses

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