Hidradenitis suppuritiva (Verneuil's disease or acne inverse)

chronic condition characterized by swollen, painful, inflamed lesions in the
axillae, groin, and other parts of the body that contain apocrine glands
Pathophysiology
 inflammation and infection of the axillary apocrine glands (probably initiated
by follicular occlusion, perifolliculitis then secondary inflammation of nearby
apocrine and eccrine glands.)
 confined to areas of the body that contain apocrine glands. These areas are the
axillae, areola of the nipple, groin, perineum, circumanal, and periumbilical
regions.
 Axilla most commonly involved
Epidemiology
 1 in 600 incidence; W>M 3:1
 38% have a family history
 Flare-ups have been linked with menses; shorter menstrual cycles and longer
duration of menstrual flow are associated with the disease.
 aetiology is unknown, but polygenic factors are thought to be involved,
including diabetes, smoking and immunocompromise
 Ingrown hairs are a predisposing factor, thus an increased incidence of the
disease occurs in patients with tightly curled hair.
Clinical
 characterised by induration, deep sinus tract formation and recurrent abscess
formation
 does not present prior to puberty because the apocrine glands are inactive
until triggered by a surge in sex hormones. The condition may be observed
in patients of any age after puberty.
 Recurrent symmetrical lesions occur soon after puberty, typically in the groin,
axillae, perineum and breasts, as well as at sites of shearing such as the neck,
inframammary crease and waist
 most common presentation is that of painful, tender, firm, nodular lesions
under the arms
 Once established, the condition may be suppressed, but not cured, by
antibiotics.
 Excision of the involved skin and glands is the only cure; such resections are
generally quite disfiguring.
 In chronic cases, may develop lymphoedema, contractures and SCC ((in
indolent sinus tracts))
Nonsurgical management
 Avoid local irritants – deodorants, shaving, tight clothing
 excessive underarm adiposity may worsen disease - Weight loss may help
 Infectious diseases consult
o Long term preventative antibiotics - no evidence that chronic suppressive
antibiotic therapy alters the natural history of hidradenitis
o Skin treatments


Optimise other comorbidities especially diabetes
Other medications
1. Retinoids (inhibits sebaceous gland function and abnormal keratinization)
2. hormonal - finasteride
3. Corticosteroids
4. radiotherapy
5. CO2 laser
6. cryotherapy
Surgical management
 Acute infections require
o incision and drainage
o only topical antibiotic that has been proven effective in a randomized
controlled trial is clindamycin
 Medical management is often temporising
 Radical excision offers the results – plan for this during quiescent periods
 Early, rather than delayed, wide excisional therapy is recommended because
lower disease severity allows for more surgical options.
En bloc resection
o Limited excision results in high recurrence rate
o Some suggest that apocrine glands are concentrated at the junction of hair
bearing axilla and up to 2cm beyond
 Reconstruction options
1. Direct closure
 only possible with limited excision
 avoid scar contracture with lazy S incision or Z plasty
 70% recurrence rate
2. Intermediate thickness SSG
 Poor graft take - may be helped with VAC dressing on top (Ann
Plast Surg 2001)
 High risks of contracture and recurrence
3. Skin substitute
 Biobrane (nylon mesh, silicone membrane, crosslinked porcine
collagen peptides (PRS 2005)
 Inhibits wound contracture
 allows egress of bacteria and fluid
 Epithelialization from wound margins as all skin
appendages were removed during excision
4. Flap coverage
 Random flaps – Limberg
 double opposing V–Y advancement islanded fasciocutaneous flaps
(Geh BJPS 2002)

Parascapular fasciocutaneous flaps - axial pattern based on the
descending scapular artery (Ann Plast Surg 2003)

Thoracodorsal artery perforator flap
 Based on perforators from lateral branch of thoradorsal
artery over lattisimus dorsi.
Medial arm flap
 Dominant artery – branches of superior ulnar collateral
artery(septocutaneous perforators between biceps and long
head triceps)
