Epidemiology, Pathology, and Treatment of Axillary Hidradenitis Suppurativa

The Journal of Emergency Medone, Vol 4. pp 369-378, 1966 Pmted in the USA l Copyrtghl 18 1986 Pergamon Journals Ltd

EPIDEMIOLOGY, PATHOLOGY, AND TREATMENT OF AXILLARY HIDRADENITIS SUPPURATIVA

Richard F. Edlich, MD, PhD,* Kimberly A. Silloway, BA,* George T. Rodeheaver, PhD, * Philip H. Cooper, MDt

The Emergency Medical Serwce and the Departments of *Plastic Surgery and tPathology, University of Virginia School of Medicine, Charlotteswlle, Reprmt address: Richard F. Edlich, MD, PhD. Department of Plastic Surgery, Uwersity of Virginia, School of MedIcme, Charlottesville. VA 22908

0 Abstract-The epidemiology, pathology, Introduction and management of axillary hidradenitis suppurativa were examined in 11 patients with this Axillary hidradenitis suppurativa (HS) is disease. On the basis of this study, the follow- an inflammatory disease of the skin and ing predisposing factors were incriminated in subcutaneous tissue. The condition typi- the epidemiology of the disease: predilection cally has an insidious onset with pruritus of the disease for women, obesity, hair removal and hyperhidrosis being the earliest symp- by a safety razor, antiperspirants and deodorants, and local pyogenic infections distant toms. As time progresses, the inflamma- from the axilla. Because antiperspirants do not tory process spreads to adjacent axillary effect transepidermal water loss of axillary skin, eventually resulting in extensive skin, their potential deleterious effects are epithelialized sinus tracts within fibrotic probably related to their chemical irritant ef- dermal tissue. Recurrent infections result fects on cut, nicked, or irritated axillary skin. in a putrid, foul-smelling drainage that Treatment of this disease will vary accord- causes affected patients to limit their so- ing to its severity. Incision and drainage are cial contacts to the immediate family and usually needed to treat the localized disease. security of their homes.’ On the basis of a Specific measures must also be instituted to comprehensive review of the literature, prevent progression of the disease (eg, weight Mustafa et al2 concluded that there was a reduction, avoidance of safety razor and antiperspirants and deodorants, and control of lo- paucity of information about axillary HS. calized pyogenic infections distant from the The etiology is unknown and there is no axilla). Management of the chronic phase of standard treatment. the disease is primarily excision of infected ax- In an effort to gain insight into the epi- illary skin. demiology, pathology, and management of this disease, the medical records of 11 0 Keywords- axillary hidradenitis patients with axillary HS were reviewed. suppurativa; obesity; safety razor; Each patient was interviewed to identify antiperspirants and deodorants; pyogenic factors that predisposed to this condition. infections The patient’s pathologic specimens were

RECEIVED: 23 January 1986; ACCEPTED: 4 June 1986 0736-4679/86 $3.00 + .OO 369 R. F. Edlich, K. A. Silloway, G. T Rodeheaver, P H. Cooper examined to determine more precisely the of application (ie, roll-on, aerosol, etc) histopathology of axillary HS. Experi- was ascertained. The patients were ques- mental studies in normal human subjects tioned about any adverse reactions (ie, were also initiated to ascertain the possible pruritus, inflammation, etc) to the anti- role of antiperspirants and deodorants in perspirant or deodorant that may have this disease process. The results of these preceded the onset of HS. clinical and experimental studies consti- tute the basis of this report. Histopa thology

Material and Methods Microscopic sections of 14 excision speci- Clinical Data mens of axillary skin from nine patients were reviewed. The number of slides per Patients were selected for this study by specimen ranged from four to 15. Many surveying the medical records of the Uni- of the excisions included normal axillary versity of Virginia Hospital over a ten- skin with abundant apocrine glands, so year time interval (1973-1983). Eleven that direct comparisons between normal patients with HS were identified during and abnormal tissue were often possible. this period of time. Clinical data were de- Particular attention was paid to the type rived from a retrospective review of their and extent of inflammatory changes hospital medical records and from person- (chronic, subacute, and acute), the loca- al interviews of all patients with axillary tion of such changes within the specimen, HS. The following information was ob- and their spatial relation to squamous- tained: race, sex, age, patient weight when lined sinus tracts. The presence or absence symptoms of HS first appeared, anatomic of eccrine and apocrine coils within af- location of HS, initial treatment prior to fected skin was recorded, and acute or hospitalization, operative treatment, and chronic inflammation of either eccrine or associated local and systemic illnesses. apocrine coils was specifically evaluated. Personal interviews were directed at identifying possible factors that contributed to the development of HS. The pa- Antiperspirants and Transepidermal tients were asked to estimate the rate of Water Loss sweat production from their axillae. The diagnosis of hyperhidrosis was based on One possible mechanism by which anti- the subjective impressions of the patients perspirants and deodorants predispose to and was judged to occur when sweating HS is that they form an occlusive film that was typically noticeable under conditions interferes with transepidermal water loss where it would not normally be expected. (TEWL), thereby increasing moisture on The women were questioned as to their the skin surface, which in turn encourages method of hair removal from their axillae bacterial proliferation. The validity of (ie, safety razor with stainless steel blade, this hypothesis was tested by measuring electric razor). The patients were asked if the changes in TEWL following topical they encountered any adverse reactions to application of either antiperspirants or hair removal (nicking or cutting of skin) deodorants. The Evaporometer EPl devel- that were clinically disturbing and seemed oped by Nilsson and Lamke* was chosen to contribute to the development of HS. because it obtains noninvasive, reproduc- The patients were also asked if they used ible measurements of TEWL.4 Calibration any antiperspirant or deodorant prior to their illness. Information regarding the brand name of the product and the vehicle *Servomed Company, Stockholm, Sweden. Axlllary Hidradenitis Suppurative 371 of the instrument was accomplished prior and deodorant, while the other axilla was to the measurement and at 3-month inter- treated with MitchumTM? antiperspirant. vals as suggested by the manufacturer. The active ingredient in each antiperspi- Reproducibility of measurements ob- rant was an aluminum zirconium tetrach- tained by different users of the instrument lorhydrex glycine complex. The site of ap- was demonstrated during preliminary tri- plication of each antiperspirant in each als. To ensure maximal reliability, all mea- patient was randomized. Using similar surements were made by the same investi- contact pressures, the roll-on antiperspi- gator on the same day in a closed room in rants were applied uniformly over the axil- which the humidity and temperature were lary skin. A new container of antiperspi- approximately constant. Care was taken rant was used for each axilla. The to ensure even contact pressure of the statistical significance of the measure- probe to the skin, a significant variable ments was determined by the Student’s f that must be controlled. test. Transepidermal water loss was determined in seven healthy women volunteers (three black, four white) whose ages Results ranged from 18 to 20 years and who were not obese, as judged by the guidelines of Demographic and clinical details of the 11 Blackburn et al.’ Healthy volunteers were patients under study are shown in Table 1. selected for this phase of this study be- Each had one or more predisposing fac- cause the deodorants and antiperspirants tors that could have contributed to the de- can be spread uniformly over their axillary velopment of HS. When the patient’s skin. In contrast, the scarred and infected weights were compared with the “ideal axillary skin of patients with axillary HS weight” proposed by Blackburn et al,’ all is not susceptible to a uniform application the women were judged to be overweight of these deodorants and antiperspirants. to a degree that ranged from 2 to 47 kg The subjects were not permitted to use ei- (Table 2). The two men were not obese. ther antiperspirants or deodorants for seven Four women and one man had subjective days prior to the study. Each subject re- complaints of hyperhidrosis that preceded mained in the room for at least 30 minutes the onset of HS. before the experiment. They were required All patients used an antiperspirant or to remain seated prior to measurements. deodorant prior to developing HS. Six During the measurements the subjects lay complained of adverse reactions (ie, pruri- supine with both arms extended to 180” to tus, burning sensation, inflammation, in- provide exposure of both axillae. A 2 x 2- fection) that they thought were related to cm area in each axilla was identified by the development of HS. The types of anti- making four dots with a marking pen in perspirants that elicited adverse reactions each corner of the square to ensure that are listed in Table 3. In each case, the vehi- the site of measurement was the same in cle for transfer of the active ingredient was each axilla. a roll-on applicator. Acne vulgaris was The measurements of TEWL were tak- noted in one male patient prior to the on- en ten minutes prior to and 30 minutes af- set of HS. ter the topical application of roll-on anti- All women used razors with stainless perspirants. One axilla of each subject was steel blades to remove hair from their axil- subjected to Right GuardTM* antiperspirant lae. Three of the women had complaints of nicking or cutting the skin after shaving

*Gillette Personal Care Division, Boston, Mass. tRevlon Inc, New York, NY. 372 R. F. Edlich, K. A. Silloway, G. T. Rodeheaver, f? H. Cooper

Table 1 Anatomic Location Adverse Reactions

Patient Age* Axilla No. (Y) Sex Race R L Groin Obesity Hyperhidrosis Antiperspirant Shaving

1 47 F W ++ - + - 2 47 F 0 ++ - + - + - 3 33 F W ++ - + + + + 4 25 F W ++ - + + + + 5 49 F W ++ - + - - 6 34 F W +- - + - + - 7 14 F W ++ - + + + + 8 24 F B ++ + + + - 9 26 F W ++ - + - - 10 33 M B ii - + + - lit 25 M W + + - - - -

‘Initial Onset of KS. tHistory of acne vulgaris.

Table 2. Weight of Patients With HS

Patient Sex Ideal Weight Difference No. Weight (kg) (kg) (kg)

1 F 61 81 +20 2 F 62 88 +6 3 F 56 58 +2 4 F 61 77 +16 5 F 56 86 +30 6 F 61 84 +23 7 F 62 109 +47 8 F 62 86 +24 9 F 58 82 +24 10 M 74 74 0 11 M 79 73 -6

Table 3. Antiperspirants

Cases (No.) Type Vehicle

2 MitchumrM Roll-on 2 Right GuardTM Roll-on 2 Aridrv* Roll-on

*Carter Wallace, New York, NY. prior to the onset of HS. These adverse sistent change in TEWL of axillary skin reactions to the razor caused them to dis- (Figure 1A). In three volunteers there was continue the use of their antiperspirants a slight increase in TEWL (3%-16%), or deodorants. while a decrease in TEWL (6%-58%) was Treatment with Right GuardTM antiper- detected in the remaining subjects. Simi- spirant and deodorant resulted in no con- larly, MitchumTM antiperspirant had no Axillary Hidradenitis Suppurative 373

+60 +50 F

-50 -60 t

Figure 1. There was no consistent change in TEWL of axillary skin after application of either Right Guard*M antiperspirant and deodorant (A) or Mitchum TM antiperspirant (B). T signifies total for group with mean and standard deviation.

statistically significant effect on TEWL of curred without infection in all patients. axillary skin (Figure 1B). Topical applica- No shoulder disability, contractures, or re- tion of this antiperspirant was associ- currence of the disease was encountered. ated with an increase in TEWL of axillary Microscopically, all specimens exhibi- skin in three subjects (7%-40%), and a ted marked chronic inflammatory decrease in TEWL in four subjects changes. There was extensive scar concen- (lo%-40%). trated in the deep dermis and subcutane- Treatment of each patient consisted of ous tissue. The scar contained patches of surgical excision of the diseased skin and lymphocytes and plasma cells and scat- all hair-bearing skin with a l-cm margin tered multinucleate giant cells, a few of of normal uninvolved skin. The excision which contained fragments of keratin. was extended down to deep fascia. In nine Both eccrine and apocrine coils were es- patients the wound was closed with mini- sentially absent within scarred areas and mal undermining (about 3 mm along each intact hair follicles were sparse. Em- edge) using interrupted 3-O absorbale su- bedded within the scar were variable tures in the dermis and interrupted 4-O numbers of sinus tracts lined by keratin- monofilament nylon skin sutures. In two forming, stratified squamous epithelium. patients split thickness skin grafts were re- Some of the sinuses connected with sur- quired to resurface axillary wounds. Be- face epidermis via orifices that, except for cause the wounds in all patients were in- their larger caliber, were indistinguishable fected with a penicillin-resistant strain of from infundibula of hair follicles in adja- Staphylococcus aureus, a cephalosporin cent, uninvolved skin. Rarely, such ori- or a penicillinase-resistant penicillin was fices contained hairshafts. The foregoing administered intravenously immediately changes had a distinctly segmental distri- before surgery, during surgery, and con- bution. The borders between normal-ap- tinued for two days postoperatively. Pro- pearing skin and abnormal tissue were of- phylactic drainage of the primarily closed ten abrupt. Rare eccrine and apocrine wounds was not employed. Healing oc- coils in affected areas exhibited chronic in- 374 Fi. F. Edlich, K. A. Silloway, G. T. Rodeheaver, P. Ii. Cooper flammation and fibrosis of their stroma tures to a specific follicle. In no sections when situated at the margins between nor- did we observe superficial suppurative mal and involved tissue, but none exhibi- folliculitis. ted acute inflammation. The epidermis throughout most of the The specimens from two of nine pa- sections had a distinctly folded, accordi- tients had histologic changes limited to on-like configuration. It was covered by a those just described. In addition to chron- prominent layer of dense keratin. The ori- ic changes, specimens from the remaining fices of normal follicles were typically seven patients exhibited both subacute wide, and follicular infundibula had gob- and acute inflammatory reactions. These let-like or distended contours, Typically, were typically situated adjacent to and ap- they were partially or completely filled peared to involve epithelial-lined sinuses. with keratin. There were large patches and horizontally oriented tracts of edematous granulation tissue containing numerous capillaries, Discussion large numbers of lymphocytes and plasma cells, and scattered multinucleate giant The development of infection is deter- cells. In some instances the lining of the mined, in part, by a delicate balance be- adjacent sinus was intact, but in other foci tween the number of bacteria present and there were segmental erosions of the lin- the tissue’s resistance to infection. Experi- ing. The lumens of the affected sinuses mental studies performed in our laborato- were either empty or contained remnants ry demonstrated that the critical infective of keratin and sparse inflammatory cells. dose of pure cultures of obligate and fa- Granulation tissue adjacent to sinuses not cultatively aerobic bacteria was one mil- infrequently contained flakes of keratin. lion bacteria or greater per gram of tis- Acute inflammatory changes, when pres- sue.6 The type of aerobic bacteria was less ent, consisted of dense neutrophilic infil- important in the development of infection trates. These were typically mixed with the than the number. granulation tissue. Short segments of epi- Host defenses of patients with axillary thelium lining sinuses were heavily infil- HS are usually normal.’ Nevertheless, trated by neutrophils and showed promi- since the axilla is warm, moist, and con- nent degenerative changes. Purulent tains abundant secretions, it is a veritable exudate was sparse or absent within haven for microorganisms sufficient in sinuses, and there was little tendency for number to cause infection if the integu- the exudate to extend upward within them ment is disrupted. In their study of axil- toward the epidermis. Direct extension of lary microbial axillary flora in 25 healthy acute inflammatory exudate through the subjects, Shehadeh and Kligman” found superficial dermis to the epidermal sur- that most organisms were gram-positive, face was not seen. coagulase-negative staphylococci and co- Only three sections in two cases exhibi- ryneform bacteria. The latter bacteria are ted acute inflammation of rare apocrine gram-positive, nonspore-forming pleo- coils. These were situated in skin that was morphic rods. The aerobic coryneform otherwise normal. There were neutrophils bacteria of the skin are commonly known in the stroma and lumens of secretory units as diphtheroids, a name coined to indicate and marked degenerative changes of apo- a close association with the diphtheria ba- crine epithelium. Portions of the coils cillus. The general term coryneform is were completely obliterated by inflamma- more appropriate to these skin bacteria, tory changes and lacked recognizable epi- because they resemble Cornybacterium thelium. Despite serial sections, it was not diptheriae in little, but morphology. possible to relate inflamed apocrine struc- Staphylococci were present in nearly Axlllary Hidradenitis Suppurative 375

100% of axillae; coryneform bacteria in associated with well-documented deleteri- more than 75%. The resident flora of these ous effects.14 A safety razor consists of a healthy subjects also included the gram- blade held in a fixed geometry by the negative Aerobacter species and Alkali- head. The razor blade transects the infun- genes fecalis in almost one half and one dibulum of the hair follicle so that the third the individuals, respectively. The av- wounded hair follicle provides access and erage bacterial counts of the right and left substrate for bacteria? In addition, the axillae of these 25 subjects were almost impermeable cornea1 layer is damaged, re- identical (2.36 millions/cm and 2.59 mil- sulting in an exudate that supports bacte- lions/cm, respectively). On the whole, in- rial proliferation. In our experimental ani- dividual variations from week to week mals, bacteria inoculation of shaved skin were tolerably small, while the average resulted in dermatitis. In contrast, skin weekly counts were strikingly constant. whose hair was removed by either an elec- Marples and Williamson’ found that, tric clipper or electric razor was refractory on average, persons with a predominance to bacterial contamination and did not de- of diphtheroids in their axilla harbored to- velop dermatitis. The implications of the tal populations of several million per damaging effects of hair removal on the square centimeter, whereas those with skin are being recognized by surgeons. In more than 50% staphylococci averaged a prospective, randomized study by Alex- several hundred thousands total bacteria ander et al,“ the wound infection rate of per square centimeter. They also showed patients whose hair was removed by a that if the diphtheroids were selectively safety razor was significantly greater than suppressed by antibiotic treatment, the that encountered in patients in which hair staphylococci resistant to the antibiotic in- removal was accomplished by electric clip- creased proportionately. Thus, diphthe- pers. On the basis of these findings, these roids appeared to limit the growth of investigators recommended that electric staphylococci in the normal axilla. clippers should be used to remove hair In our studies several factors that ap- from the skin at the operative site and in- peared to predispose the patients to axil- dicated that hair removal by a safety razor lary HS were identified. There was a pred- is potentially dangerous, inviting the de- ilection of the disease for women. Nine of velopment of infection. Prior to the devel- our 11 patients with axillary HS were opment of axillary HS, three of our pa- women. Pigott and Ellis’” also reported tients complained of nicking or cutting of that axillary HS primiarily affected wom- axillary skin by a safety razor prior to the en (six of eight cases). In other series of onset of HS. This interruption of the skin axillary HS, however, the men and women allows access to the millions of the micro- were equally affected. “.‘* organisms that reside on axillary skin. As The susceptibility of a woman’s axillary in the case of the surgical patient, the ra- skin to HS may be related, in part, to the zor compromises the local tissue defenses practice of axillary hair removal with a and appears to invite the development of safety razor. Removal of axillary hair is HS. These deleterious effects of the razor aesthetically pleasing to women and is could be prevented by using an electric ra- helpful in preventing axillary odor. The zor for hair removal. presence of hair greatly increases axillary The absence of axillary hair resulting odor, because it acts as a collecting site for from shaving appears to be a peculiarity axillary secretions, debris, keratin, and to Americans as an aesthetic standard. bacteria. Shaving and careful washing of The incidence of axillary HS in women in the axilla reduces odor for more than 24 other cultures who rarely shave axillary hours.” hair has never been documented. An Shaving the skin with a safety razor is odoriferous study focusing on obese pa- R. F. Edlich, K. A. Silloway, G. T Rodeheaver, I? H. Cooper tients who refrain from shaving and using application of these agents resulted in deodorants should provide further insight burning, itching, dermatitis, and infec- into the epidemiology of this disease. tion, causing them to discontinue their The number of bacteria in the axilla is use. Several mechanisms may account for probably enhanced further by increasing the deleterious effects of these products the moisture on the axillary skin. Experi- on axillary skin. Some antiperspirants mental and clinical observations recently may produce an occlusive film over the summarized by Kligman et al3 consistently axillary skin, impairing TEWL and in- emphasized the importance of moisture in creasing the moisture content on the un- colonization of skin by potential patho- derlying skin. This hypothesis was not gens. The relative dryness of normal skin supported by our measurements of TEWL in most parts of the body contributes to before and after application of antiperspi- the marked limitation of growth of bacte- rants in seven healthy women. In our study, ria, especially gram-negative bacilli with topical application of two different an- their greater moisture requirements (Esch- tiperspirants did not significantly alter the erichia coli, Pseudomonas aeruginosa, TEWL from their axillary skin. Steiner etc). and Grayson ” believed that antiperspi- A variety of factors that can potential- rants predisposed to HS through chemical ly enhance the moisture content of axilla irritation, inducing poral closure, or have been identified in patients with HS. changing axillary flora. The warning la- Anderson and PerryI reported that 20 bels on antiperspirants lend credence to (77%) of their 26 patients with HS were their belief that antiperspirants may in- overweight. The excess weight ranged deed be chemical irritants. These labels from 2.3 to 40.7 kg, with an average of indicate to the consumer that antiper- 12.7 kg. Obesity was evident also in all spirants should not be used on broken or women with axillary HS in our study. irritated skin. Obesity is prone to increase the moisture Long-standing pyogenic infections have on axillary skin by maintaining an occlu- also been associated with the development sive skin cover over the axillary skin. In of HS. A history of acne vulgaris preced- the obese patient, the axilla is buried be- ed the development of axillary HS in a tween the enlarged lateral throacic wall male patient in our clinical study. Pigott and the upper arm. In the individual of and Ellis’” described a male patient who normal body weight, the arm does not suffered severe acne as an adolescent, with gain intimate contact with the thoracic the development of axillary HS at age lg. cage in a resting position, thus allowing The frequent occurrence of HS among exposure of the axilla and permitting persons with seborrheic type of skin and TEWL. Subjective hyperhidrosis preceded associated acne was noted by Brunsting.” the onset of axillary HS in five of our Eleven of his 22 patients with HS had pre- patients. Brunsting” reported that exces- existing pustular dermatoses, mostly in sive sweating, itching, and burning were the form of acne indurata of the face, the first symptoms of axillary HS. These neck, and back. Conway et alI8 noted that symptoms were followed by the develop- seven of their patients with HS showed ment of a firm nodule that subsequently severe acne scars of their face and trunk. drained thick purulent material. An eighth patient displayed severe epider- Mustafa and his colleague9 observed mophytosis and an active chalazion. several patients with HS whose illness was Shelley and Cahn” provided experi- exacerbated by the use of aluminum-con- mental evidence suggesting that occlusion taining deodorants. Six of our patients of the follicular orifice (which also con- thought that the application of antiperspi- ducts apocrine sweat to the surface) was rant preparations predisposed to the de- important in the pathogenesis of axillary velopment of HS. They noted that topical HS. In each of 12 normal male adult sub- Axillary Hidradenitis Suppurative 377 jects between the ages of 20 and 40 they changes appeared to have been secondary applied a perforated belladonna adhesive to segmental or extensive erosion of the tape to one axilla that had been manually sinus lining. The histologic appearances epilated. Three of the 12 developed sup- were indistinguishable from those ob- purative apocrine hidradenitis that was served in persistent and recurrently in- thought, by the authors, to be histologi- flamed epidermal cysts. Increased activity cally similar to spontaneously occurring of the disease may coincide with periodic axillary HS. Although we cannot exclude overgrowth of bacteria residing within the that this may be an important event in the sinuses and resultant damage and erosion early stage of the disease, we only ob- of sinus lining epithelium. served rare similar changes in two pa- The method of treatment varies with tients. Moreover, it has not been proven the stage of the disease. The acute phase that such lesions progress to the chronic should be treated early and intensively to condition encountered by clinicians and avoid progression into the chronic phase. pathologists and recognized as HS. Incision and drainage are usually needed All specimens in our study demonstra- to treat the localized disease. Specific at- ted chronic changes, and we believe that tention must be paid to each factor that our observations provide some further un- predisposes to axillary HS. A strict weight derstanding of the pathophysiology of reduction program must be instituted for HS. The major abnormalities consisted of all obese patients. Axillary hair must be deep dermal and subcutaneous scars; epi- removed with an electric razor rather than dermal-lined sinuses; and chronic, sub- a safety razor. Antiperspirant and deodor- acute, and acute inflammation. The su- ants should be avoided. Local pyogenic perficial half of the dermis was essentially infection (ie, acne vulgaris, etc) must be spared. Although embedded in scar, the aggressively treated. sinuses traversed normal dermis to con- Treatment of the chronic stage of axil- nect with epidermis that was usually nor- lary HS is primarily surgical. Almost all mal. It thus appears that the superficial surgeons agree that the only chance for a portions of the sinuses, including their lasting cure is complete removal of the orifices, represent dilated and elongated, hair-bearing area and underlying diseased but otherwise unaffected, infundibula of deep dermal tissue in the axilla. After ex- preexisting hair follicles. The orifices of cision of the diseased tissue, a number of the sinuses rarely contained hair shafts, surgical techniques have been recom- and the shafts were rare within scarred mended for wound closure. Primary clo- areas. It appears that early in the disease, sure has been recommended by some sur- the hair-producing portion of the follicle geons.ZO 21 Split-thickness skin grafts have is destroyed. This correlates with the pres- also been advocated to resurface large de- ence of alopecia in most of the axillary fects resulting from excision of the skin.” specimens and would indicate that residu- Satisfactory results have also been ob- al hair shafts in the dermis have little role tained using local flaps.“ O’Brien et al” in perpetuating the chronic stage of HS. used an anteriorly based Limberg flap in Both eccrine and apocrine coils were es- women and a posteriorly based flap in sentially absent from affected areas and men. are probably also destroyed relatively early during evolution of HS. The existence of the sinus tracts, Summary generated from follicular epithelium, probably accounts for the persistent clini- A comprehensive study was initiated to cal course of HS. The inflammatory determine the epidemiology, pathology, changes were concentrated around the and management of axillary hidradenitis sinuses, and the acute and subacute suppurativa (HS). In 11 patients with this 378 R. F. Edlich, K. A. Silloway, G. T Rodeheaver, I? H. Cooper disease, specific predisposing factors were localized infection and institution of spe- incriminated in the development of this cific measures to prevent progression of disease. These factors included a predilec- the disease (eg, strict weight reduction tion of the disease for women, obesity, program, avoidance of safety razor and hair removal by a safety razor, antiperspi- antiperspirants and deodorants, and con- rants and deodorants, and local pyogenic trol of localized pyogenic infection distant infections distant from the axilla. The po- from the axilla). tential deleterious effects of antiperspi- Management of the chronic phase of rants and deodorants on the axillary skin the disease is primarily surgery. All hair- do not appear to be related to its effect on bearing skin with a l-cm margin of nor- transepidermal water loss, but rather to mal uninvolved skin should be excised. their chemical irritant effects on cut, The excision should extend down to deep nicked, or irritated skin. fascia since the infected sinusoidal tracts The method of treatment of axillary involve primarily the deep dermal layers. HS varies with the stage of the disease. The technique of closure of the resulting The treatment objectives of the acute wound defect is dictated by the size of the phase is early incision and drainage of the defect.

REFERENCES

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