The diagnosis is made clinically. The location, types of lesions, comedones, and scarring are clues to diagnosing hidradenitis. Other disorders to include in the differential diagnosis of mild disease include inflamed epidermal inclusion cysts, inflamed pilonidal cysts, and furuncles. Severe disease should be distinguished from cutaneous Crohn's disease, lymphogranuloma venereum, granuloma inguinale, and actinomyces. Epidermal inclusion cysts may be singular or multiple and usually have a distinct opening (punctum) to the surface. Usually, only one cyst is inflamed at a given time. Scarring is not a characteristic finding. The patient often gives a history of the presence of a nontender flesh-colored nodule from which cheesy, foul smelling material could be expressed. Pilonidal cysts are singular and located over the coccyx or sacrum in the midline. A furuncle is a staphylococcal abscess ("boils") resulting from folliculitis. Perianal cutaneous Crohn's disease may have a very similar clinical appearance to hidradenitis with inflammatory nodules, sinus tracts, and fistulas. A thorough history and physical examination will help identify or exclude this disease. If uncertain, a skin biopsy for histopathology and culture will differentiate hidradenitis from cutaneous Crohn's disease, lymphogranuloma venereum, granuloma inguinale, and actinomyces.
As secondary bacterial infection can occur, cultures of draining lesions should be performed. Treatment
Medical and surgical treatment options exist for hidradenitis suppurativa. The therapy chosen depends on the extent and severity of the disease. Acutely inflamed nodules should be treated with intralesional corticosteroids (triamcinolone 3 to 5 mg/mL). Acutely inflamed abscesses should be incised and drained. Mild-to-moderate chronic disease should be treated with oral antibiotics in a similar manner as treating acne. This includes using tetracycline 500 mg PO bid, minocycline 50 mg PO bid, or erythromycin 500 mg PO bid for at least 1 month. If bacterial infection is discovered from bacterial culture results, antibiotic treatment should be tailored to the specific organism and its drug sensitivities. Surgical excision may be necessary if lesions do not respond to the above mentioned treatments. Such patients should be referred to a plastic or dermatologic surgeon.
In addition to the previously mentioned therapy, severe disease may require oral prednisone or isotretinoin (Accutane). Such patients should be referred to a dermatologist for management. Patients should be told about the chronicity of this disease. Aggravating factors such as tight-fitting clothing should be avoided. Obese patients should be encouraged to loose weight. Antibacterial cleansers (Hibiclens) or a topical antibiotic solution (Cleocin T) should be prescribed to prevent secondary bacterial infection.
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