Hidradenitis Simplified

“For such a chronic, debilitating disease, efficient screening of the population in the primary care setting to detect possible hidradenitis suppurativa (HS) cases early is essential, in order to facilitate early referral,”¹ noted the authors of this month’s Top Paper.¹ The authors then offered a number of succinct facts that greatly facilitated my own grasp of this disease and the primary care physician’s role in its management.

1. Definition. HS is defined as a chronic, inflammatory, recurrent, debilitating skin disease of the terminal hair follicle. It generally presents after puberty and is notable for painful, deep-seated, inflamed lesions in the apocrine bearing areas of the body—most commonly the axillary, inguinal and anogenital regions.
2. Identification. A simple historical question can help primary care practitioners easily identify persons with the disease (sensitivity 90% and specificity 97%). Ask the patient, “Have you had outbreaks of boils during the last 6 months, with a minimum of 2 boils in 1 of the following 5 locations: axilla, groin, genitals, under the breasts, and other places?
3. Differential diagnosis. What other diseases should be considered when making a diagnosis of HS? Other conditions may include Staphylococal infections, cutaneous Crohn’s disease, tumors, lymphogranuloma venereum, and a few uncommon infections (eg, actinomycosis).
4. Laboratory testing. As no lab markers exist, lab testing does not help.
5. Severity. The Top Paper¹ introduces the Hurley 3 stage severity scoring system, which uses the lesions with the presence or absence of accompanying scarring and fistulae, to gauge severity.
6. Physical examination. In an examination, look for specific locations. In order of frequency, lesions are commonly found in the inguinal, axillary, perineal, perianal, and submammary regions in women as well as the buttocks, mons pubis, scalp, and areas behind the ears and eyelids.
7. Examples. The Top Paper¹ has ample pictures of HS lesions in multiple locations. It is well worth obtaining your own copy.
8. Treatment. After a diagnosis of HS is determined, consultation is an essential next step. Dermatologists are expert in medical treatment of HS, including the use of biological agents. However, this disease is a multispecialty problem and can require surgical interventions by plastic surgeons.

HS is a chronic and seriously debilitating disease that may lead to depression and significant work disability. Primary care physicians play the vital role of making an early diagnosis and determining an appropriate referral.

Reference:

1. Zouboulis CC, del Marmol V, Mrowietz U, et al. Hidradenitis suppurativa/acne inversa: criteria for diagnosis, severity assessement, classification and disease evaluation. Dermatology. 2015;231(2):184-190.

Gregory W. Rutecki, MD, is a physician at the National Consult Service at the Cleveland Clinic. He is also a member of the editorial board of Consultant. Dr. Rutecki reports that he has no relevant financial relationships to disclose.