Australian Doctor Australian Doctor 30th June 2017 | Page 25

Therapy Update
Hidradenitis suppuritiva
affecting the axille.
PART 1
When boils ain’t boils
DERMATOLOGY
Part one of this two-part series describes how to recognise
hidradenitis suppurativa, a painful condition often
mistaken for boils.
DR OLIVIA CHARLTON, DR ROBERT ROSEN AND ASSOCIATE PROFESSOR GEOFFREY CAINS
H
IDRADENI-
TIS
suppura-
tiva (HS) is a
chronic cutane-
ous inflammatory disease
occurring primarily in the
axilla, groin, perineal and
inframammary regions.
Clinically, it is character-
ised by painful nodules and
comedones, which evolve
into deep-seated and often
discharging abscesses.
Eruption of these lesions
results in a massive local
inflammatory response, with
possible sinus tract forma-
tion and scarring. The clini-
cal features and diagnostic
criteria are summarised in
box 1.
The pain, disfigurement,
drainage and malodour that
accompany this disease con-
tribute to significant psycho-
social morbidity and have a
profound impact on quality
of life.
GPs have a crucial role
in the prompt diagnosis,
referral and ongoing man-
agement of this debilitating
condition and its associated
comorbidities.
A 2015 Cochrane Review
stressed the treatment of
HS was “currently unsat-
isfactory,” and highlighted
that the condition had been
“largely neglected by society
and the research commu-
nity.” 1 The lack of under-
standing
and
resultant
misdiagnosis is reflected in
the mean diagnostic delay
of 5-14 years. 2
Aetiology and
pathogenesis
The exact pathogenesis of
HS is not yet clear; how-
ever, genetic, endocrine,
environmental and micro-
biological
factors
are
implicated in this systemic
auto-inflammatory process.
The prevalence of HS
is frequently reported as
1%, with the disease most
commonly manifesting in
people in their early 20s. 3
However, some European
studies report the preva-
lence to be as high as 4%. 4
associated
epidemiologi-
cally with cigarette smok-
ing, obesity and metabolic
syndrome. Smoking is both
a risk factor for developing
the disease and for severe
disease.
Mechanical stress is asso-
HIDRADENITIS SUPPURATIVA HAS
BEEN STRONGLY ASSOCIATED
EPIDEMIOLOGICALLY WITH CIGARETTE
SMOKING, OBESITY AND METABOLIC
SYNDROME.
Women are more likely to
develop the disease than
men, with a female:male
ratio of 3:1. 5
HS has been strongly
ciated with worsening of
lesions through promoting
follicular occlusion and
rupture. Furthermore, the
proinflammatory
factors
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associated with obesity and
HS respectively have been
postulated to act synergisti-
cally to worsen disease.
HS has also been associ-
ated with insulin resistance,
inflammatory bowel disease
and polycystic ovarian syn-
drome