Hidradenitis supurativa in unusual sites

Introduction

Hidradenitis suppurativa is a chronic suppurative and cicatricial disease of apocrine gland bearing skin areas, principally the axilla and anogenital skin, also chest, abdomen, thigh, buttock and eye-lid. But leg involvement alone is a rare phenomenon as in the present case and on reviewing the literature through computer based ′Medline search′ we did not find any such case had been reported so far.

Case Report

A 35 year old man presented with multiple plaques on both legs, studded with pus discharging sinuses for last 15 years. The lesion started as pustules which became confluent and sometimes developed erythematous, tender nodules which ruptured and discharged pus. After a long time some lesions healed with scar and others persisted as sinuses. The patient got various mode of therapies including homoeopathy, herbal allopathy but no cure. Examination revealed about 15-20 indurated tender plaques, of size varying from 1 or 2 cm to 2x4cm, studded with multiple pus discharging sinuses. Multiple pock-like deep scars as well as diffuse atrophic and depigmented scars on the plaques were seen [Figure - 1]. Papules of lichen amyloidosis were also present on both forearms. Other areas of the skin including axilla, groin and anogenital areas were normal.

The routine testson blood, stoll and urine were withing normal limits. X-rayof the legs, didn′t show any abrormality Mantoux test, was regalive HIV test was negative pus culture showed growth of staphylococcus aureus but tissue culture found no fungi and acid fast bacilli. Biopsy revealed hyperkeratosis, acanthosis, diffuse fibrosis and dense mixed cellular infiltration specially around the follicles.

Discussion

It is well known that hidradenitis suppurativa occurs in apocrine gland bearing areas : but in more recent years the requistite paricipation of apocrine sweat glands in the genesis of hidradenitis suppurative has been questioned. Histopatholigical observation indicates the absence of apocrine ductal and secretory elements in inframammary, mammary, inguinal (laterally), thigh and buttock form of the disease, even in early lesion before obstructive and inflammatory changes have been occurred. In 1990, Yu CC et al, found that to develop hidradenitis suppurativa apocrine gland is not a must, it actually develops from hair follicles and extension of the occlusive process into apocrine glands can occur when such glands are present.[1] Many other diseases have been described in association with this condition such as pityriasis rubra pilaris2, acanthosis nigricans,3 and pachyonychia congenita.4 A tragic and extraordinary case described by Moschella showed urethral, vesical, and rectal fistulas with anaemia, hypoproteinemia, amyloidosis, renal failure and death.5 The present case was associated with lichen amyloidosis for the last 5 years.