Forum for Nordic Dermato-Venereology Nr1,2019 | Page 24

Case Report Subtle Clues in Hidradenitis Suppurativa Diagnosis D orra B ouazzi , D itte M. L. S aunte E. J emec and G regor B. Department of Dermatology, Zealand University Hospital, Roskilde Hospital; Health Sciences Faculty, University of Copenhagen, Denmark. E-mail: [email protected] H idradenitis suppurativa (HS) is an inflammatory disorder of the apocrine gland-bearing regions of the skin, which presents with recurrent painful nodules and suppuration. The primary nodules may develop into abscesses and tunnels (si- nus tracts) and scarring (1). Patients often go years without a diagnosis, resulting in repeated courses of ineffective medical treatments, such as dicloxacillin, and surgical procedures, such as attempted incision and drainage. It may be speculated that, despite clear clinical diagnostic criteria for HS, for some less-experienced doctors, differential diagnosis may still not be well-established. When diagnosing HS it is sometimes important to look for sub- tle clues in the form of typical morphological manifestations (2), some of which are described in the clinical cases below. O bservations Case 1 A 22-year-old woman presented to the Department of Derma- tology, Zealand University Hospital, Roskilde with a painful ery­thematous fluctuating abscess > 2 cm on her left buttock (Fig. 1). A thorough examination revealed a red inflamed nodule (< 1 cm) in the axilla (Fig. 2). A closer look at the sur- rounding skin in the axilla revealed other important findings Fig. 2. Case 1: Lesion in the right axilla with scars and tombstone comedones (arrows). that helped to make the clinical diagnosis of HS, namely the presence of tombstone (pseudo) comedones. This is a mor- phological manifestation of HS that may help to differentiate between a simple abscess and HS. This distinction is important, as an incision and drainage pro- cedure would probably have been performed if an infectious abscess was suspected, but due to the findings in the axilla that showed clear morphological manifestations of HS (i.e. tombstone comedones) and an inflamed nodule, treatment with intralesional triamcinolone was chosen to reduce local inflammation. In the absence of soft fluctuation, incision and drainage would have been inappropriate due to its low efficacy and high recurrence rate (3). In addition, the patient stated that both her father and brother had a history of recurrent boils. It is therefore noteworthy to emphasize the importance of asking about the patient’s family history and to look for HS-specific clues (also to examine other anatomical regions). Case 2 Fig. 1. Case 1: Erythematous abscess on left buttock (arrow). 22 A woman consulted the Department of Dermatology, Zealand University Hospital, Roskilde due to a nodule in the groin (Fig. 3). The patient reported purulent discharge and pain. Forum for Nord Derm Ven 2019, Vol. 24, No. 1