Hidradenitis Suppurativa Axillaris

Hidradenitis suppurativa is an inflammatory disease which has a predilection for certain regions of the body, such as the axillae, groins, breasts, and perianal area. It occurs more frequently than is generally recognized, and is often diagnosed as abscess, furunculosis, or carbuncle. By far the most common site is the axilla. It is with hidradenitis suppurativa axillaris that this report is mainly concerned. It is based on a series of 58 cases seen in the past ten years. Almost a century ago this entity was first recognized by Verneuil (1), a French surgeon, who clinically associated the abscesses with the apocrine sweat glands. In contradistinction to the eccrine or ordinary sweat glands, which are derived from the epidermis and are distributed over almost the entire surface of the body, the apocrine glands originate from the hair follicles which develop with puberty and are commonly found in the skin of the axillae, mammae, genitalia, perianal and inguinal regions. Histologically, the apocrine sweat glands are larger than the ordinary eccrine glands. They are situated in the folds of the skin and are therefore prone to infection because of the friction to which they are subjected. The infection tends to assume a chronic form, due to the tortuosity of the excretory ducts of these glands, which impedes drainage. Although the exact etiology of hidradenitis is obscure, it is due, in most instances, to external causes, such as local inflammatory processes, irritation by depilatories or shaving, the friction of tight clothing, and excessive sweating. It is more common in the warm than in the cold months of the year. According to Tachau (2), a small percentage of the cases (10 per cent) represent a complication of a local or generalized inflammatory dermatosis, such as eczema, contact dermatitis, epidermatophytosis, erythrasma, or arsphenamine dermatitis. Hidradenitis suppurativa is associated with a variety of bacteria, probably the most common offender being the Staphylococcus pyogenes aureus (possibly the albus or citreus as well). Pathologically, the apocrine sweat glands are involved in an inflammatory reaction which progresses to suppuration. As in all infections, there is a polymorphonuclear and lymphocytic infiltrate which tends to progress to a chronic stage. By contiguity other glands in the same location become involved, so that in a single region one may observe two or more areas of infection in various stages of the inflammatory process. The infection spreads from the primary focus by way of the lymphatics and tissue spaces in the skin and subcutaneous tissues. In the early stages, a small hard mass is seen, resembling an ordinary boil or furuncle, which goes on to suppuration. The furuncle either opens spontaneously or is lanced, when only a small drop of pus is expressed, leaving behind a hard marble-like nodule. In favorable cases this residual mass slowly goes on to resolution.