Let’s Shine a Light
As I entered the room for the patient interview, she approached me quietly requesting that I would examine her without a chaperone present. I hurriedly explained our policy. “The chaperone serves to protect both of us in the exam environment,” I stated firmly. As she listened intently to my words. Her next words caught me off guard. “ It’s just that it’s embarrassing”. I had no idea what she meant but saw deep sadness in her eyes and conceded that I would evaluate her alone. The medical assistant was to stay behind the curtain while I performed the physical exam.
The patient was advised to completely undress and she donned the clinic gown and prepared for the examination. I proceeded with my usual evaluation but noted that under her armpits and under her breasts had several nodules which were draining pus and were in different stages of healing. Between her breasts also had lesions which were red and raised and appeared to be on the verge of popping. The armpits exam revealed firm areas with what appeared to be tracts tunneling under the skin. I was now acutely aware of what she was so concerned about. “When it gets like this it smells and it is really hard to deal with,” she quipped, her eyes gazed down to the floor. “How long has this been going on I asked?” She reported it had been going on for years and that she had gone from doctor to doctor without much help. She would be given antibiotic after antibiotic and at one point had surgery for the same condition in the groin area. On evaluation of the pelvis I saw the scarring that had resulted from the disease and the evidence of the surgical removal she had mentioned.
Hidradenitis suppurativa is the name of her condition. It is a chronic inflammatory disease that disproportionately affects women of childbearing age. It is caused by the hair follicles becoming plugged and the hair unit becomes dilated and ruptures causing an inflammatory reaction. As to why some patients have this is unclear it could be genetics, hormonal fluctuation, immune system problems or environmental. Patients with this disease may go for a long time without the proper diagnosis and may end up bouncing from one provider to another. Many patients suffer because of the delay in diagnosis which can lead to increased draining tunnels and scarring. There is no need to biopsy or take x-rays to make the diagnosis. It is made on the basis of history and physical examination with findings that are characteristic of the disease. It is important to note that other diseases can mimic hidradenitis supprativa lesions such as vaginal cysts, Crohn’s disease on the skin, sexually transmitted infections with skin manifestations or cancer. It is important to have a high level of suspicion and continue to monitor the condition in order to establish the correct diagnosis. Things that can clue in a provider are patients with recurring boils, acne lesions and follicular inflammation. There are staging criteria called Hurley staging (1-3). The staging is based on abscess formation, tracts, drainage and scarring.
Treatment is comprehensive including lifestyle changes, wearing clothes that are 100% cotton, menstrual care to avoid friction from sanitary napkins, hair grooming to limit follicular inflammation, tobacco cessation and dietary modifications. Birth control pills can be used to limit the fluctuation in hormones and decrease the flares in disease.
Management of the disease is usually based on the its severity. It begins with antiseptic washes, topical treatments, oral antibiotics, hormonal therapy and migrates to biological agents and surgical management. One of the most important aspects is having a team approach to the care of the patient. In most cases women see their Obstetrician and Gynecologists more often and so we are on the frontline and able to make a diagnosis early on. The team approach helps to keep all providers in sync with the care and management of the whole patient. Early diagnosis is key to preventing some of the longterm consequences of the disease.
I had seen hidradenitis before but for the first time I had insight into the pain and embarrassment that accompanied the disease. The breast exam was difficult as she had some pain. I slowly navigated the exam which was in the midst of a flare and then moved to the pelvic exam. She tolerated the pap exam and the bimanual exam (where we examine the pelvis using our hands).
In addition to the hidradenitis the patient was borderline diabetic and had not experienced a regular menstrual cycle for years. I was able to discuss her risk factors and establish a holistic plan to work with her primary doctor. Additionally, I referred her for bariatric and general surgery consultations.