An unusual case of breast cancer masked by hidradenitis suppurativa

Lesional Inflammatory Profile in Hidradenitis Suppurativa Is Not Solely Driven by IL-1

Hidradenitis suppurativa and associated factors: Still unsolved problems

The only definitive treatment of chronic axillar hidradenitis suppurativa (HS) that prevents relapses is 'in toto' excision of the infected glandular tissue. This way a deficiency emerges, which needs to be restored. Reconstruction with split skin graft (SSG) is a most common way of recovery, but thoracodorsal artery perforator (TDAP) fasciocutneous flap delivers better functional and aesthetic results. Between May 2014 and July 2016, 14 patients underwent reconstructive surgery after excision of axillary HS, 2 of them had bilateral lesion. In 15 cases TDAP was used, in 1 case we used thoracodorsal artery capillar perforator flap (TAPcp). In all but 2 cases 1 dominant perforator was found. 1 flap had 2 dominant perforators and 1 flap was supplied by capillary perforators. Size of the flaps spread between 6 × 8 and 10 × 15 cm. 15 reconstructions were successful, 1 flap necrotised because of the lack of compliance of the patient. As a result of the glandular tissue excision carried out because of a chronic HS, a deficiency emerges. TDAP flap is an ideal solution for surgical reconstruction of axillar deficiencies, and a great alternative to SSG.

Current insight into the histopathological course of events during disease progression in hidradenitis suppurativa (HS) is fragmentary. To identify histological alterations and leucocyte subsets in normal-appearing perilesional skin, and early and chronic HS lesions. In this observational study we examined eight perilesional skin samples, and six early and 10 chronic prototypic HS lesions, as well as skin samples from four healthy donors using in situ immunostaining. Perilesional skin showed mild psoriasiform hyperplasia and follicular plugging as well as a low-grade influx of tryptase-positive mast cells, CD3+ T cells, CD138+ plasma cells and factor XIIIa+ dendritic cells. In early HS lesions, neutrophilic abscess formation and influx of mainly macrophages, monocytes and dendritic cells predominated. In chronic disease, the infiltrate expanded with markedly increased frequencies of CD20+ and CD79a+ B cells and CD138+ plasma cells. As in early lesions, free keratin fibres were detected in the dermis and within giant cells. Single detached keratinocytes and strands of follicular epithelium were observed in the dermis, the latter frequently expressing Ki67, indicative of active proliferation. Psoriasiform hyperplasia, follicular plugging and low-grade leucocytic infiltration are already present in normal-appearing perilesional skin. Keratin fibres in the dermis are associated with clinical disease. Early lesions are characterized by neutrophilic abscess formation and influx of mainly histiocytes, and chronic lesions mainly by expansion of B cells and plasma cells in 'pseudo' follicles. Proliferating strands of follicular epithelium may initiate fistula formation. Mast cells are increased in all stages of HS including perilesional skin.

Vulvar squamous cell carcinoma complicating hidradenitis suppurativa in a young woman

Hidradenitis suppurativa (HS) is a chronic recurrent inflammatory condition presenting with painful, deep-seated abscesses and sinus tracts in multifocal locations. Rarely, long-standing inflammation in HS may lead to serious complications, such as cutaneous squamous cell carcinoma (SCC) (also termed Marjolin ulcer). Herein, we report a case of invasive cutaneous SCC arising from chronic ulcers of a HS patient. A 40-year old Korean male, a current smoker with 20 pack-year history, presented with a history of painful, recurrent, deep-seated abscesses and ulcers on the buttocks since his late teens, thus classified as Hurley stage III. A large purulent ulcer developed on the right buttock several months ago. Initial treatment was focused on controlling infection and facilitating wound healing. The lesion showed 50% reduction of size in 6 weeks, but also developed foul odor and showed fungating margins. Multiple skin biopsies were consistent with invasive SCC. Magnetic resonance imaging revealed a few enlarged lymph nodes on the right inguinal area, which was confirmed as metastasis on frozen biopsy. Slow Mohs micrographic surgery and radical right inguinal lymph node dissection was done. Incidence rates of SCC arising from HS have been reported up to 4.6%. To our knowledge, this is the first report of cutaneous SCC arising from HS in Korea. Our case emphasizes that the diagnosis of cutaneous SCC in HS should not be delayed, and early surgical intervention is crucial for better outcomes.

Hidradenitis Suppurativa and Pediatric Crohn Disease

e13099 Background: Reports on delay to diagnosis of cancer in young women are based on retrospective studies and conflicting. The purpose of this study was to investigate time to cancer diagnosis in women presenting to a surgeon with breast-related complaints; and particularly, the role of age. Methods: A population-based cohort study including all women aged 18 to 44 presenting to a surgeon with a breast-related complaint between 2005 and 2015 in a large Israeli healthcare plan (N = 157,264). We collected data including demographics, diagnosis codes, breast imaging and biopsies. Breast cancer diagnosis within one year of the visit was ascertained from the national cancer registry. Time to breast imaging and biopsy was compared between the different age groups. Logistic regression analysis was used to determine the association between age and delay to biopsy while adjusting for possible confounders. Results: During the first year after the visit, 45,434 (29%) women had a breast imaging study; 5,767 (3.7%) women had a breast biopsy; and 676 (0.43%) were diagnosed with breast cancer. Overall, time to first breast imaging (mean, 53 days) and biopsy (mean, 68 days) did not differ significantly between the age groups. Non-specific visit codes (other than breast mass) were associated with delays to imaging and biopsy. This was more pronounced in the women ultimately diagnosed with breast cancer. Among women diagnosed with breast cancer, age under 40 (OR 2.3, 95% CI 1.4; 3.9), being post-partum (OR 2.6, 95% CI 1.1; 5.9) and a non-specific visit code (OR-8.3, 95% CI 4.9; 14.2) were associated with delay to biopsy. Conclusions: Symptomatic women with lower a-priori likelihood of breast malignancy (younger age, post-partum, or non-specific visit code) are at a significantly greater risk of delayed diagnosis of cancer. Physicians should be aware of the challenging diagnosis in young women with non-specific symptoms.

Squamous cell carcinoma (SCC) arising from chronic hidradenitis suppurativa (HS) is rare; however, the morbidity associated with this presentation is high and management has not been standardised or optimised. We present a case of HS of the perineum and buttocks complicated by SCC, requiring multiple extensive surgical resections. Adjuvant radiotherapy was withheld initially because of concern for poor healing of the surgical wound but was eventually initiated after a second recurrence was identified. The patient ultimately expired 4 years after the initial diagnosis of SCC. We also review 80 cases of SCC complicating HS found in the English literature. Case reports and mechanistic studies suggest the possibility that human papilloma virus and smoking may be risk factors associated with SCC in HS. Despite the majority of SCC cases being well-differentiated tumours in HS, the highly aggressive nature of SCC in HS and its high likelihood for rapid progression, recurrence, metastasis and high mortality suggests the need to advocate for aggressive treatment. We recommend an aggressive approach to management at the time of SCC diagnosis in HS, which includes appropriate imaging to establish the extent of the tumour, large and deep surgical excision, sentinel lymph node evaluation, consultation with radiation oncology for potential adjuvant radiation therapy and close surveillance.

Hidradenitis suppurativa (HS) is an inflammatory skin disorder typically affecting the groin, inframammary folds, and axillae. HS is characterized by the development of boils, abscesses, fistulas, and sinus tracts. Due to the inflammatory destruction of lymph vessels, patients with long-standing HS may develop lymphedema. Most commonly reported in the literature is lymphedema involvement of the genital and anal regions. In this case report, we describe unilateral breast skin changes in a patient with HS. The patient was extensively worked up for inflammatory breast cancer, and eventually underwent stereotactic biopsies. Subsequently, these biopsies were consistent with lymphedema due to her chronic HS. Although rare, there is a paucity of literature describing breast lymphedema associated with HS. As breast lymphedema due to HS may mimic inflammatory breast cancer, it is important for providers to firstly rule out malignancy and place lymphedema high on the differential when examining and treating these patients.

Background: Delay in diagnosis may be a contributing factor to the observed correlation between young age and advanced disease. We examined time to cancer diagnosis in young women presenting to surgeons with breast-related complaints. Materials and Methods: This population-based cohort study included all women aged 18-44 presenting to a surgeon with breast-related complaints between 2005 and 2015 in a large health care plan (n = 157,264). Data included demographics, diagnosis codes, and workup. Cancer diagnosis was ascertained from the national cancer registry. Time to breast imaging and biopsy was compared between the different age groups. Logistic regression analysis was used to determine the association between age and delay to biopsy while adjusting for possible confounders. Results: During the 1st year after the visit, 45,434 (29%) women had breast imaging; 5,766 (3.7%) women had a breast biopsy; and 676 (0.43%) were diagnosed with breast cancer. Overall, time to first breast imaging and biopsy did not differ significantly between the age groups. But nonspecific visit codes (other than breast mass) were associated with delays to imaging and biopsy. Among, women diagnosed with breast cancer, age under 40 years (odds ratio [OR]: 2.3, 95% confidence interval [CI]: 1.4-3.9), being postpartum (OR: 2.6, 95% CI: 1.1-5.9), and a nonspecific visit code (OR: 8.3, 95% CI: 4.9-14.2) were associated with delay. Conclusions: Symptomatic women with lower a-priori likelihood of malignancy (younger age, postpartum, or nonspecific visit code) are at significantly greater risk of delayed diagnosis of cancer. Physicians should be aware of the diagnostic challenge in young women presenting with nonspecific symptoms.

Hidradenitis suppurativa (HS) is a morbid, recurrent skin condition that presents a major challenge to clinical therapy. Investigation into the pathogenesis of HS has implicated local and systemic pro-inflammatory cytokines, particularly TNF-α and IL-17A, as major determinants of disease progression and severity. This has ushered in a revolution in HS therapy with biologics targeting these cytokines. We report a case of a 36-year-old man with extensive and treatment-resistant Hurley Stage 3 HS. After undergoing numerous unsuccessful trials of topical, systemic, and biologic therapies, secukinumab therapy with 150 mg weekly injections was initiated. HS clinical response was seen after 20 weeks and was maintained for almost two years. Secukinumab 150 mg or 300 mg once weekly may be an effective and safe therapeutic option for moderate-to-severe chronic HS. J Drugs Dermatol. 2022;21(12):1358-1360. doi:10.36849/JDD.6752.

Surgical Treatment of Hyperhidrosis and Chronic Hidradenitis Suppurativa

Hidradenitis suppurativa is a chronic inflammatory skin disorder characterized by painful recurring pustules, nodules, abscesses, and sinus tract formation. Secondary lymphedema associated with hidradenitis suppurativa is an uncommon but severe condition, often resulting in significant morbidity. Although the exact link between lymphedema and chronic hidradenitis suppurativa is not fully understood, the chronic inflammatory process with scarring is a likely an important factor. Herein, we reported a 52-year-old man with untreated chronic hidradenitis suppurativa, nonalcoholic fatty liver disease-related cirrhosis, and secondary massive scrotal lymphedema, complicated by cellulitis and sepsis. Despite appropriate treatment, the patient's condition deteriorated and he unfortunately passed away two weeks after hospitalization. Additionally, we reviewed the literature on hidradenitis suppurativa-associated lymphedema, analyzing data from 51 patients. The majority were men with long-standing severe hidradenitis suppurativa. Surgical intervention was identified as the most commonly effective treatment modality, offering substantial improvements in function and appearance. However, some patients experienced postsurgery adverse events. In conclusion, this report highlights the importance of early detection and management of hidradenitis suppurativa and its complications to prevent patients' significant morbidity.

Keywords: anaerobes; hidradenitis suppurativa; inflammatory disease; microbiology; soft tissue and skin infections