Tuesday, October 4, 2022

Hidradenitis Suppurativa Sinus Tract Formation

Complications With Sinus Tracts

Deroofing of sinus tracts in Hidradenitis Suppurativa for Healthcare Professionals

In many cases, especially if left untreated, a mild case of hidradenitis suppurativa will worsen, leading to the formation of sinus tracts and abscesses.

In stages II and III of the disease, sinus tracts may appear. These are tunnel-like cavities that form under the skin and can interconnect. The tunnels often cause pain and scarring.

Abscesses may also form in stages II and III of the disease. An abscess is a larger lump that holds pus. In hidradenitis suppurativa, the abscesses may join together and be very painful. They may break open and leak pus, blood, and fluid. These sores can stain clothes and also cause a foul smell.

The constant bursting-then-healing of abscesses can cause permanent scarring.

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When To See A Doctor

Many people with HS may not seek medical help right away. This is sometimes due to a previous misdiagnosis of cystic acne or other chronic skin conditions. Unlike traditional acne though, HS tends to recur in the same areas and it wont respond to over-the-counter treatments.

Talk with a doctor about your skin condition if you experience one or more of the following:

  • boil-like lesions that develop in the folds of your skin, such as the groin, breast, or neck area
  • lesions that recur in the same areas
  • symmetrical boils that affect both sides of your body equally
  • areas of skin that are extremely painful and interfere with your daily activities

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What Are The Signs And Symptoms Of Hidradenitis Suppurativa

Hidradenitis suppurativa usually starts with a single inflamed, boil-like, firm, raised skin lump . Sometimes this stage can result in itching but usually there is discomfort or pain.

The nodule either slowly disappears or remains to become a draining collection of pus . Abscesses are usually very painful.

Eventually, healing occurs but the affected skin is permanently damaged, leaving deep scarring. In more severe disease the affected areas spread. Either single or multiple abscesses occur. The formation of tunnels , called sinus tracts, causes the overlying skin to feel hard and lumpy .

A staging system can be used to describe the severity of the disease:

  • Stage 1 – here there are either single or multiple areas affected but the abscesses are separate from one another. There is no scarring or sinus tract formation.
  • Stage 2 – involves recurrent abscesses which can be single or multiple. Although there are sinus tracts, the affected areas are usually widely separated.
  • Stage 3 – generally, large areas are affected with multiple interconnected sinus tracts and abscesses.

For some people, the disease is extremely distressing and painful, with a constant succession of new nodules and abscesses forming as soon as older ones have finally healed.

What Causes Hidradenitis Suppurativa

Sinus Tract Formation in Hidradenitis Suppurativa 3D Ultrasound Study ...

The cause is not well understood. It is thought to happen due to blockage of the hair follicles on the skin, or the sweat gland openings themselves. This blockage could be from sweat itself, or skin secretions, such as sebum from the sebaceous glands. The blocked sweat gland continues to make sweat. The sweat cannot escape on to the skin surface and so is forced deeper into surrounding tissue. Germs that normally live on the skin surface may have been trapped in the blocked gland or hair follicle. The germs can multiply in warm moist surroundings. As the sweat is forced back deeper into the tissues, it takes with it the germs. This leads to inflammation and sometimes to infection. This is how the hard boil-like lumps are thought to form to start with. As the problem becomes worse, abscesses, which contain pus, develop.

It may also be that the sweat glands in some people don’t develop correctly and completely. These glands might not allow the sweat they make to reach the skin surface. Instead, the sweat is trapped and travels into the surrounding tissues. There may also be an excessive response by the body’s immune system, causing the inflammation.

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What Is Hidradenitis Suppurativa

Hidradenitis suppurativa is a long-term inflammatory skin disease with recurrent boil-like lumps. These boils often become bigger and turn into collections of pus . The abscesses leak pus and become difficult to heal.

The problem affects only areas of the skin containing apocrine sweat glands.

Commonly, the problem affects the groin and armpits. Other areas are sometimes affected such as under the breasts and on the vulva, the scrotum, the buttocks and the skin in front of the anus . Women tend to develop it more commonly in the armpits, in the groin and under the breasts. Men more commonly develop disease that affects the skin around the anus.

The wounds caused by the boils and abscesses heal poorly, leaving scars. In severe cases, the pus tunnels down under the skin surface. The tunnels formed are called sinus tracts. Multiple areas of hidradenitis can become linked under the skin surface, by a network of interconnected sinus tracts. This means the inflammation travels deeper and becomes more widespread.

The eventually healed areas are full of thick scar tissue. The scarring left behind can be as unsightly as the discharging wounds.

What Is The Hurley System

Hidradenitis suppurativa symptoms can range from mild to severe. In 1989, a dermatologist named Hurley developed a scoring system based on the presence of wounds that have formed tunnels under the skin and scarring to diagnose the diseases progression.

Dubbed the Hurley Stages, this system is now used to classify people with hidradenitis suppurativa into three categories based on the severity of symptoms:

  • Stage I: Mildest form of the disease, which presents with solitary pus-filled lumps or formations of multiple abscesses that are isolated no sinus tracts or scarring
  • Stage II: Presents with abscesses that recur, formation of sinus tracts, single or multiple lesions that are widely spaced
  • Stage III: The most severe progression with widespread development of lesions, presenting with multiple abscesses and sinus tracts that interconnect

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The Future Of Hidradenitis Suppurativa

The field of HS has come a long way since Velpeau first described it in 1839. Much of the advancement has resulted from recent studies in all areas of HS, from epidemiology to pathophysiology to comorbid disease associations and novel treatment options. Still, HS is largely misunderstood by much of the medical community and the general population, leading to unacceptable delays in diagnosis and treatment. In the future, further awareness of HS should be one of the primary goals. This will lead to an earlier diagnosis, better patient outcomes, improved psychosocial support, and ultimately increased funding for research to find a cure for this devastating and frustrating disease.

Do I Need Any Tests To Diagnose Hidradenitis Suppurativa

Hidradenitis Suppurativa – Mayo Clinic

There are no tests used to diagnose hidradenitis suppurativa. The diagnosis is usually based on the typical signs and symptoms that a person may have.

Sometimes hidradenitis suppurativa is confused with other similar-looking skin conditions such as common boils, collections of pus , skin infections and ingrowing hairs. Other diseases can cause tunnels known as sinus tracts – for example, Crohn’s disease. Tests might be needed to exclude these other conditions, although they often have many other symptoms.

Sometimes, if there are signs of infection, small samples can be taken. This is to see what germs are growing in the pus. This can help in deciding whether antibiotic medicines should be used.

Occasionally, it might be helpful to test your blood for sugar to make sure you do not have diabetes. This is because skin infections are more common in people with diabetes. Your doctor might also take blood tests to make sure you are not anaemic and to monitor the level of infection or inflammation.

Scans, such as CT scans, are not needed to diagnose the condition. They may, however, be used in very severe disease, to plan surgery, as it is important to know where the sinus tracts go and how deep they are.

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Treatment Of Hidradenitis Suppurativa

  • Depends on severity

For people with a mild case of hidradenitis suppurativa, a doctor injects corticosteroids into the area and prescribes antibiotics, such as tetracycline, minocycline, erythromycin, or clindamycin, to be taken by mouth for about 7 to 10 days. Clindamycin and resorcinol creams applied to the skin are also given, and people should wash the area with benzoyl peroxide. All of these drugs may be used together or alone.

For people with a moderate case of hidradenitis suppurativa, a doctor gives the same oral antibiotics as for mild cases, and sometimes rifampin , but for a longer period . Doctors may give women drugs that block the effects of male sex hormones, such as oral contraceptives, spironolactone, or finasteride. The doctor may cut open the abscesses to drain the pus. Sinus tracts are opened and drained.

For people with a severe case of hidradenitis suppurativa, a doctor gives infliximab or adalimumab to reduce inflammation. Isotretinoin or acitretin , taken for several months, may reduce inflammation. If the disorder continues, a doctor cuts out the involved area and then repairs the skin or does a skin graft. Laser treatment Using Lasers to Treat Skin Problems to remove the damaged skin or hair may also be done.

Management Of Hidradenitis Suppurativa

Hidradenitis suppurativa has a significant impact on quality of life and can be very difficult to treat. Treatment options include both medical and surgical intervention in addition to addressing the pain and psychological impact that accompanies the disease. Although there is no cure, many effective evidence-based treatments are available to control disease progression and improve symptoms. The goal is not only to manage flares but also to help reduce their recurrence. Treatment regimens should be tailored to each patient and are based on disease severity and lifestyle factors. Attention to the effect of HS on the patients quality of life is important, with referrals as needed to counseling and other supports.

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What Is The Outcome For Hidradenitis Suppurativa

Hidradenitis suppurativa tends to improve in pregnancy in those who usually have flares during menstruation. Normal vaginal delivery is possible unless the patient has extensive painful genital lesions.

HS is a chronic scarring condition. Spontaneous remission may occur with time, but scarring persists.

Early diagnosis and treatment are required to minimise lasting damage.

Associated And Exacerbating Factors

Sinus Tract Formation in Hidradenitis Suppurativa

Many exacerbating factors have been identified in HS, although the triggers differ among patients. Obesity and nicotine smoking are two of the most well-known associations in HS, although sweating, shaving, depilation, deodorant use, and friction have also been implicated . In the past several years, a different trigger has been identified: diet.

In 2010, Melnik proposed a link between high glycemic foods and worsening acne. He noted that many of the proposed triggers in acne and HS converge into one pathway, the phosphoinositol-3 kinase/Akt/Fox01 pathway, which may play a role in the disease .

In 2013, Tara Grant, an HS sufferer, wrote a book entitled The Hidden Plague: A Field Guide for Surviving and Overcoming Hidradenitis Suppurativa . In this book, Tara details her 20-year experience with HS and how she overcame the disease by modifying her diet. This book has led many patients and researchers to take a closer look at the role of diet as a possible trigger. Although it is certainly plausible that diet may contribute to the severity of HS, it is important to acknowledge that a decrease in BMI may be a confounding factor in patients who have had success through modification of their diet. Overall, the link between diet and HS exacerbations is not well established. Further prospective, controlled studies are needed to evaluate the role of diet in HS.

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Recurrent Abscesses Scarring And Sinus Tract Formation: The Clinical Presentation Of Hidradenitis Suppurativa

Sara M. James, MD, and Barbara B. Wilson, MD

The first of a 4-part series outlines the clinical presentation of hidradenitis suppurativa, including appearance, characteristic lesions, and differential diagnosis.

ABSTRACT: Hidradenitis suppurativa is a chronic disease presenting with recurrent abscesses, scarring, and sinus tract formation. The condition is most common in the intertriginous areas, including the axillae, groin, and perineal area. Its pathophysiology is not completely understood, but follicular occlusion is believed to be the key pathologic event. Bacterial infection is likely a secondary feature of the disease. Treatment of HS varies with disease severity. Mild disease can be treated with topical antibiotics, but systemic antibiotics, hormonal therapies, laser therapy, and biologic agents are used to treat more severe or refractory disease. Surgery is required for definitive treatment. Patients with HS experience pain and embarrassment and are more likely to experience depression. In this 4-part series, the authors provide an overview of HS, detailing its clinical presentation, grading systems used to score HS severity, the pathophysiology of the disease, and methods of treatment.

Clinical Presentation

References:

  • Jemec GBE, Heidenheim M, Nielsen NH. The prevalence of hidradenitis suppurativa and its potential precursor lesions. J Am Acad Dermatol. 1996 35:191-194.
  • Jemec GBE. Hidradenitis suppurativa. N Engl J Med. 2012 366:158-164.
  • What Is The Long

    The outlook is very variable. Not everyone progresses from stage 1 to stage 3.

    For many affected people, hidradenitis suppurativa is a painful and debilitating condition. It has a tendency to flare up regularly, gradually causing more problems. Deep scarring and formation of tunnels , called sinus tracts, are not uncommon.

    Some people have mild disease only. Early surgical treatment can cure the disease and stop it from returning. In rare cases, the condition goes away on its own without treatment.

    The condition can prevent normal working and social activities . Psychological problems are common, as are difficulties in sexual relationships. These problems can either be directly due to the pain and messiness of the condition or to embarrassment and body image problems. As a result, it can cause a less good quality of life.

    Further reading and references

    • Zouboulis CC, Desai N, Emtestam L, et al European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa. J Eur Acad Dermatol Venereol. 2015 Apr29:619-44. doi: 10.1111/jdv.12966. Epub 2015 Jan 30.

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    Are There Any Complications From Having Hidradenitis Suppurativa

    The main complication is scarring of the skin and deeper tissues. In severe cases, this can cause swelling of the arm or of the leg . This is called lymphoedema. This means that the fluid drainage from the limb is affected and the fluid builds up, causing the swelling. It is a difficult problem to treat and cure often, tight elastic compression garments have to be worn long-term.

    Other complications include:

    • Long-term infection leading to problems such as anaemia, kidney problems and low levels of protein in the blood.
    • Joint pains and inflammation .
    • Skin cancer. This is rare but has been reported in very severe long-term hidradenitis suppurativa.
    • Fistula formation. A fistula occurs when channels, called sinus tracts, tunnel into other parts of the body, such as the bowel or bladder .

    Reconstruction After Radical Wide Excision

    What is Hidradenitis Suppurativa?

    The choice of the reconstructive technique largely depends on the size and location of the defects. Reconstruction after radical wide excision is important to maintain function, reduce contracture, and provide good aesthetic outcomes. Nicoli et al. described an innovative treatment for severe HS using an innovative and alternative method with platelet-enriched plasma to promote neovascularization and a dermal substitute named Hyalomatrix , a delivery system for hyaluronic acid, to induce neodermis at the wound bed and to stimulate regeneration in a humid and protected environment. The procedure was well tolerated and achieved complete wound healing after 2 months. No recurrence was observed during the 1 year after the surgical procedure, as well as no wound dehiscence and no scar contractures occurred.

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    Who Develops Hidradenitis Suppurativa

    Around 1 in every 100 people in Europe have hidradenitis suppurativa, meaning it is quite common. Many people will have very mild problems with it.

    Hidradenitis suppurativa usually affects people between puberty and middle age. It is three times more common in women than in men. It is rare in Asian people and far more common in white-skinned people or Afro-Caribbean people.

    Hidradenitis suppurativa only develops after puberty. This is because the sweat glands are activated by hormones called sex hormones, the levels of which increase during puberty. The problem tends to improve for women if they take the combined oral contraceptive pill , or if they are pregnant. It rarely occurs after the menopause. These things all suggest that hormones play a part in causing this disease.

    The disease can run in families but the exact pattern of inheritance is not known.

    Hidradenitis suppurativa is more common in overweight or obese people and in cigarette smokers. Obesity and smoking are not direct causes. However, they can be thought of as risk factors. Hidradenitis suppurativa also seems more common in people with acne and possibly in women with polycystic ovary syndrome.

    Submammary Hs: Options For Reconstruction

    There have been few case reports in the literature regarding surgical treatments of HS lesions in the submammary area. Moosa et al. reported aggressive treatment of HS by performing bilateral mastectomies. Although this is certainly a curative option, the breast contour is disturbed. In 2010, a successful treatment of a patient with HS of the submammary area based on the procedure typical for breast reduction was described. The overall cosmetic result was good with no recurrence and a high degree of patient comfort and satisfaction .

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