25669 Abscess formation of nasal flap area four years after reconstruction, 4 months after new-onset hidradenitis suppurativa

Abstract

Hidradenitis suppurativa (HS) is an inflammatory condition characterized by recurrent nodules, abscesses, and sinus tracts. This case involves a 54-year-old Caucasian male that had a basal cell carcinoma removed from the left nasal ala, requiring 3 stages of Mohs surgery with a paramedian forehead flap. His final reconstruction was completed in November 2016 with no ensuing issues. He later presented in April 2020, with complaints of a tender fluctuant area where the reconstruction was performed. Of note, he was recently diagnosed with hidradenitis suppurativa, with symptom onset in January 2020. His history is notable for diabetes mellitus and hypertension, with increased tobacco use in the 6 months prior. Examination demonstrated an erythematous, tender nodule on the left nasal dorsum, along with superficial ulcerations in the bilateral axilla. No sinus tracts or fistulas were appreciated. Incision of the nodule drained 2 mL of white pus, with immediate pain relief. Doxycycline was initiated, and follow-up visit 2 weeks later showed near-complete resolution of the nose and axilla lesions. The median age of onset of HS is 32 years, with a predominantly female 3:1 ratio, thus making this present case uncommon. While infection is the most common postoperative complication seen in paramedian forehead flap reconstruction surgery, abscess formation 4 years later is highly unusual. Prior literature demonstrates the potential for koebnerization of HS, or an isomorphic response at areas of traumatized, but previously uninvolved skin. This theory could explain this abscess formation, albeit in a uniquely delayed fashion, at the prior flap site.