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Hidradenitis Suppurativum

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Hidradenitis Suppurativum Nigel A. Scott MD FRCS Royal Preston Hospital Greek- hidros=sweat & aden=glands develop during mid puberty sweat contains fatty materials ... – PowerPoint PPT presentation

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Title: Hidradenitis Suppurativum


1
Hidradenitis Suppurativum
Nigel A. Scott MD FRCS Royal Preston Hospital
2
Hidradenitis Suppurativum
  • Greek- hidrossweat adenglands

Painful, inflamed lesions in the axillae, groin,
and other parts of the body that contain apocrine
glands ..painful eruptions and malodorous
discharge
3
Quality of Life and Hidradenitis
J.M. Von Der Werth, G.B.E. Jemec (2001)
Morbidity in patients with hidradenitis
suppurativa British Journal of Dermatology 144
(4), 809813.
4
Hidradenitis Suppurativum
Apocrine Sweat Glands
  • develop during mid puberty
  • sweat contains fatty materials that are broken
    down by bacteria main cause of sweat odour
  • emotional stress increases production of sweat

5
Hidradenitis Suppurativum
Apocrine
6
Hidradenitis Suppurativum
not Apocrine
7
Hidradenitis Suppurativum
  • occlusion of the hair follicle (rather than the
    apocrine gland) due to a defect in terminal
    follicular epithelium

8
Hidradenitis Suppurativum
  1. occlusion of the hair follicle (rather than the
    apocrine gland) due to a defect in terminal
    follicular epithelium
  2. bacteria invade the apocrine system via the hair
    follicles, become trapped beneath the keratinous
    plugs, and multiply rapidly in the apocrine sweat

9
Hidradenitis Suppurativum
3. glands rupture and spread the infection
extending the tissue destruction and skin damage
10
Hidradenitis Suppurativum
3. glands rupture and spread the infection
extending the tissue destruction and skin damage
4. bacterial superinfection with streptococci,
staphylococci, and coliforms - BUT cultures from
lesions are frequently sterile and antibiotics
are not curative
11
Hidradenitis Suppurativum
  • chronic acneiform infection of the cutaneous
    apocrine glands
  • involves adjacent subcutaneous tissue and fascia
  • hallmark - is sinus tracts (which can become
    draining fistulas) in the apocrine gland body
    areas.

12
Hidradenitis Suppurativum
Apocrine Gland distribution
  • axillae
  • periareolar, intermammary
  • pubic area,
  • infraumbilical midline,
  • gluteal folds,
  • genitofemoral areas
  • perianal region.

13
Hidradenitis Suppurativum
14
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15
Stage 3 Hidradenitis Suppurativum
Stage 1 Single or multiple abscesses form,
without sinus tracts and cicatrization Stage
2 Recurrent abscesses with tract formation and
cicatrisation - single or multiple widely
separated lesions. Stage 3 Diffuse or
near- diffuse involvement or multiple
interconnected tracts and abscesses are observed
across the entire area
16
Hidradenitis
2-4 population 4F1M
17
Gender and disease location
Area(s) of involvement Male (n 15) Female (n 42) P value
Axilla 2 (13) 37 (88) lt.0001
Unilateral 1 (50) 19 (51) NS
Bilateral 1 (50) 18 (49)
Inguinoperineal 13 (87) 5 (12) lt.0001
Unilateral 1 (8) 4 (80) .0131
Bilateral 12 (92) 1 (20)
Axilla and inguinoperineal 1 (7) 3 (8) NS
Kagan et al. Surgical treatment of hidradenitis
suppurativa A 10-year experience Surgery
2005138(4)734-741
18
Hidradenitis medical options
  • topical clindamycin
  • hormonal cyproterone acetate ethinyloestradiol
  • retinoids
  • infliximab

19
CO2 Laser J Amer Acad Derm 200247280-285
20
Hidradenitis surgical options
  • drainage of sepsis 100 recurrence
  • laying open of tracks
  • wide local excision /- skin grafts

The surgical option of choice for late stage HS
is wide local excision with healing by secondary
intention Surgical treatment of hidradenitis
suppurativa Br J Surg 1992 79 863-6.
21
Hidradenitis surgical options
Axillae wide local excision secondary healing
22
Hidradenitis surgical options
Genitofemoral wide local excision secondary
healing
23
Genitofemoral wide local excision secondary
healing
24
Genitofemoral wide local excision secondary
healing
25
Genitofemoral wide local excision secondary
healing
26
Genitofemoral wide local excision secondary
healing
27
Perianal Hidradenitis
28
Hidradenitis surgical options
Perianal Disease differential diagnosis
  • Crohns disease
  • Cryptoglandular sepsis
  • pilonidal disease
  • tuberculosis, actinomycosis etc

29
Anal Canal Hidradenitis
  • the distal two thirds of the skin of the
    anatomic anal canal contains hair follicles with
    sebaeceous and apocrine glands
  • hidradenitis supprativum rarely involves the anal
    canal
  • if it does it tracks subcutaneously and not
    across the sphincter
  • it never tracks above the dentate line

30
Anal Canal Hidradenitis
Crohns
Cryptoglandular
Hidradenitis
31
Hidradenitis surgical options
Perianal Disease differential diagnosis
32
Perianal Hidradenitis
  • drainage of sepsis
  • laying open of tracks
  • wide local excision /- skin grafts
  • ? colostomy

33
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34
Perianal Hidradenitis
wide local excision secondary healing
35
Perianal Hidradenitis
wide local excision secondary healing
36
Perianal Hidradenitis
wide local excision secondary healing
37
Kagan et al. Surgical treatment of hidradenitis
suppurativa A 10-year experience Surgery
2005138(4)734-741
38
Kagan et al. Surgical treatment of hidradenitis
suppurativa A 10-year experience Surgery
2005138(4)734-741
39
Hidradenitis surgical outcomes
Ritz et al Extent of surgery and recurrence rate
of hidradenitis suppurativa Int J Colorectal Dis
199813164-168.
  • 31 patients 6F23M
  • mean age 31yrs
  • surgery
  • 6 abscess drained
  • 14 limited excision, 2 suture
  • 11 wide local excision

40
Ritz et al Extent of surgery and recurrence rate
of hidradenitis suppurativa Int J Colorectal Dis
199813164-168.
Drainage
Local Excision Suture
WLE
41
Hidradenitis Suppurativum
Summary
  • common cause of serious morbidity 1-4 4F1M
  • occlusion of the hair follicle (rather than the
    apocrine gland) due to a defect in terminal
    follicular epithelium
  • axilla/ inguinogenital, perianal
  • Stage 3 Diffuse or near- diffuse involvement or
    multiple interconnected tracts and abscesses are
    observed across the entire area
  • medical - topical clindamycin, oral
    contraceptive
  • perianal differential diagnosis
  • wide local excision best results with or without
    mesh skin graft

42
The DoH said "The department has accepted the
need for change and the revised approach will now
be tested with junior doctors, selectors, deanery
recruitment teams and employers."
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