Infection of the Cutaneous Apocrine Glands

A 39-year-old man presented with painful, tender, firm, nodules on his back, neck, and groin. The inguinal lesion had opened and was draining pus spontaneously.

The patient had a history of similar eruptions that began after puberty, at around 18 years of age, and recurred yearly about every 3 months. He had multiple scars as a result of numerous incision and drainage procedures. Some nodules had grown to the size of a baseball and yielded 4 to 5 mL of discharge. No one in his family had similar lesions. His medical history was unremarkable. He smoked cigarettes but otherwise led a healthy lifestyle.

Recurrent swollen, painful, inflamed nodules with draining fistulas in the axillae, groin, back, neck, and face are characteristic of hidradenitis suppurativa-a chronic acneiform infection of the cutaneous apocrine glands. Incision of the lesions yields a cheesy discharge (see inset). In this patient, culture of the discharge grew Staphylococcus epidermidis.

Hidradenitis can present as a primary condition, or it may be associated with other diseases, such as Graves disease, Crohn disease, certain forms of arthritis, Down syndrome, irritable bowel syndrome, and Sjgren syndrome. An association between hidradenitis suppurativa and cigarette smoking has been suggested.¹

Treatment depends on the disease stage. Incision and drainage provides temporary relief for patients with early, limited disease.² Those with early disease may also benefit from hydrotherapy, warm compresses, avoidance of tight clothing near the affected area, avoidance of heat and humidity, stress management, and weight loss. Acute lesions can be treated with short-term antibiotic therapy or intralesional corticosteroids. For recurrent lesions, long-term antibiotic therapy, certain oral contraceptives (in women), oral retinoids, systemic corticosteroids, and immunosuppressants (eg, cyclo-sporine and methotrexate) have been tried. These therapies have been effective in some patients. Wide excisional therapy has been used to treat severe disease.

The lesion on this patient's back was drained, and the inguinal lesion was treated with oral antibiotic therapy. He was educated about the possible association of hidradenitis suppurativa with cigarette smoking and the overall benefits of smoking cessation.

References:

REFERENCES:

1.

Freiman A, Bird G, Metelista AI, et al. Cutaneous effects of smoking.

J Cutan Med Surg.

2004;8:415-423.

2.

Shah N. Hidradenitis suppurativa: a treatment challenge.

Am Fam Physician

. 2005;72:1547-1552.