Hidradenitis Suppurativa Research Paper

Hidradenitis suppurativa is a chronic inflammatory cutaneous disorder that involves the infundibular terminal follicles in areas rich in apocrine glands and associated with the formation of abscesses and fistulating sinus1. It may affect any area of the body surface, but most often it affects the skin of the axillae and inguinoperineal regions. The incidence is reported to be as high as one in 3002. The clinical course is variable, ranging from mild cases characterized by the frequent appearance of papules, pustules, and a few inflammatory nodules to more severe cases demonstrating deep fluctuant abscesses, draining sinuses, and severe band-like scars.

Although the pathophysiology is poorly understood, it is believed that obstruction of the

apocrine and follicular pores could result in glandular dilatation and bacterial superinfection with subsequent gland rupture disseminating infection throughout the subcutaneous tissue plane. Bacterial infection is usually considered as a secondary event in the pathogenesis3. Consequently, hidradenitis will be associated with chronic painful abscesses, multiple odiferous draining sinus tracts, and chronic fibrosis with range-limiting scar formation4. However, when the abscesses extend deeper into the subcutaneous tissue, intercommunicating sinus tracts develop, resulting in irregular hypertrophic scars5. Rarely, the chronic inflammation may lead to malignant transformation to squamous cell carcinoma6.

Hidradenitis suppurativa is not life threatening, but the pain, odor, drainage, and disfigurement associated with it regularly have deleterious effects on the patient quality of life.

Patients often experience feelings of sadness or depression related to the disease, and sense of shame may contribute to self-imposed social

isolation7.

Although many exogenous factors such as the use of deodorants and shaving are believed to be causal, they have not been proven to be significantly responsible for developing hidradenitis suppurativa8. Smoking is more prevalent in patients with hidradenitis suppurativa, but the etiological basis is still unknown. Based on the observation of the exceedingly high rate of smokers among patients with this condition, it could be concluded that cigarette smoking is a major triggering factor of hidradenitis suppurativa9. Obesity is an exacerbating factor, and weight loss can help control the disease severity10.

According to Hurley's Staging System11, Hidradenitis suppurativa can be classified into three clinical stages:
Stage I: abscess formation, single or multiple without sinus tracts and scarring.

Stage II: recurrent abscesses associated with sinus tracts and multiple scarring; the presence of a single or multiple separated lesions.
Stage III: a diffuse or almost diffuse involvement or multiple interconnected tracts and abscesses.

The ideal treatment of hidradenitis suppurativa should provide a high percentage of cure and a low recurrence rate, as well as a minimal inconvenience and loss of work time. Medical management is the recommended modality in early stages while surgery should be performed as soon as possible following the formation of abscesses, fistulas, scars, and sinus tracts12.

The most common reported treatment for the early-stage cases could be summarized into:
1) A topical (clindamycin) or systemic antibiotics (tetracyclines, clindamycin, rifampicin).
1) Topical antiseptics and intralesional corticosteroids (triamcinolone acetonide).
3) Systemic retinoids (isotretinoin, etretinate).
4) Antiandrogen therapy (cyproterone acetate,

finasteride).
5) Immunotherapy (TNF alfa inhibitors).
6) Oral immunosuppressive agents (cyclosporin)
All had shown a positive effect on the disease progression4.

However, for most cases of advanced hidradenitis suppurativa, radical surgery can be the only curative treatment option13. It was reported that the early wide surgical excision is necessary and efficient to prevent many complications, lower the recurrence rate, and to improve the quality of life14.

Due to a paucity of high-quality data, definitive evidence-based guidelines for the management are lacking. Also, the variable clinical features and the unpredictable course of the disease make a uniform approach to the treatment impractical. As a result, there are multiple therapeutic approaches to this disease. Therefore, in this study, we aim to analyze the results of a modified conservative tissue preserving management protocol for grade I axillary hidradenitis suppurativa.