Radiology Case Reports

Volume 8, Issue 3, 2013

Hidradenitis suppurativa: Mammographic and sonographic manifestations in two cases

Tiffany M. Newman, MD; Monica M. Sheth, MD; Allison Levy, MD; and Kemi Babagbemi, MD

Hidradenitis suppurativa is a chronic debilitating disorder of the skin manifested by recurrent, painful, inflammatory, subcutaneous nodules. The lesions occur most commonly in the apocrine-gland-bearing skin sites such as the axillae and inguinal regions; they cause scarring and disfigurement from the forma- tion of multiple abscesses and fistulous tracts within the skin. We report the radiologic manifestations of two cases of hidradenitis suppurativa in women who presented for breast imaging.

Introduction Case report 1 Hidradenitis suppurativa (HS) is a chronic debilitating A 42-year-old woman with systemic lupus erythematosus skin disorder involving recurrent development of tender presented for followup after radical surgical excision of the inflammatory subcutaneous nodules and occurring mainly bilateral axillae with flap reconstruction, approximately 17 in apocrine-gland-bearing skin sites. Most commonly af- years prior, for HS. She was concerned for recurrence of fected locations are the flexural skin of the axillae, inguinal, HS in her left axilla. On physical examination, she had anogenital, and submammary regions as well as the in- severe acne affecting multiple locations: bilateral cheek framammary fold, chest, scalp, retroauricular, eyelid, but- acneiform eruptions, scattered scaly patches on the scalp, tock, and pubic areas (1-3). This condition often presents as right axillary tender erythematous nodules with purulent recurrent comedones, abscesses, fistulous tracts, and scar- drainage, and bilateral groin tender erythematous nodules. ring. Although HS affects only 1% of the population, it is Mammography demonstrated a 1.1-cm skin-based lesion important to understand, as patients with it can present for in the left axilla (Fig. 1). Same-day sonography showed an breast imaging evaluation of an axillary lump. intradermal, complex cystic lesion with prominent periph- A limited number of case reports are available in the eral vascularity and a sinus tract leading from the cyst to literature that review the imaging features of HS. We dis- the overlying skin surface. This lesion was felt to represent a cuss the clinical and imaging manifestations of two patients recurrent HS lesion. with HS who originally presented to our women’s imaging facility for evaluation.

Citation: Newman TM, Sheth MM, Levy A, Babagbemi K. Hidradenitis suppurativa: Mammographic and sonographic manifestations in two cases. Radiology Case Re- ports. (Online) 2013;8:737

Copyright: © 2013 The Authors. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 2.5 License, which permits reproduction and distribution, provided the original work is properly cited. Commercial use and derivative works are not permitted. Figure. 1. 42-year-old woman with hidradenitis suppurativa. A) Left The authors are all at the New York Presbyterian-Weill Cornell Medical Center, New MLO view shows an asymmetry in the region of the palpable York NY. Contact Dr. Newman at [email protected]. marker. B) Spot compression of the area shows that the lesion

Competing Interests: The authors have declared that no competing interests exist. persists. C) Tangential view demonstrates the subcutaneous loca- tions of the lesion. DOI: 10.2484/rcr.v8i3.737

RCR Radiology Case Reports | radiology.casereports.net! 1! 2013 | Volume 8 | Issue 3 Hidradenitis suppurativa: Mammographic and sonographic manifestations in two cases

Followup breast sonography three months later demon- strated a palpable hypoechoic, irregular, parallel lesion with central echogenic material and associated peripheral vascu- larity located within the skin, in the same area as a prior cyst (Fig. 2). A second new intradermal hypoechoic, oval, parallel, cystic lesion, possibly representing a sebaceous cyst or new HS lesion, was also identified adjacent to the known lesion (Fig. 3).

Figure 4. 42-year-old woman with hidradenitis suppurativa. A new subcutaneous mass was noted in the right axillary region. A) Transverse grayscale ultrasound shows a superficial oval hy- poechoic mass with a parallel orientation. B) Color Doppler ultra- sound shows evidence of flow at the periphery of the hypoechoic mass.

irritation. On physical examination, a sinus tract near a hair follicle in the area of concern within the left axilla was noted. Clinically, the physical exam findings were most consistent with recurrent infection. Mammography per- formed at that time was negative for malignancy. On ultra- Figure 2. 42-year-old woman with hidradenitis suppurativa. Trans- sound, a complex cystic mass with intrinsic echogenic ma- verse color Doppler ultrasound shows a superficial oval mass in the terial and mild increased peripheral vascularity was identi- left axillary region with evidence of peripheral blood flow. fied just beneath the left axillary dermis (Fig. 5). A sinus tract connecting the complex cystic mass to the superficial focally inflamed skin was suggested.

Figure 3. 42-year-old woman with hidradenitis suppurativa. Trans- verse color Doppler ultrasound shows a hypoechoic superficial oval mass in the left axillary region with evidence of peripheral blood flow.

Additionally, a new subcutaneous cystic lesion with the same features as the other lesions was palpated and seen on ultrasound within the right axilla (Fig. 4).

Case report 2 A 24-year-old woman with a family history of HS in a sister presented with a tender, palpable, left axillary lump Figure 5. 24-year-old woman with hidradenitis suppurativa. Com- for the past 6 months with waxing and waning tenderness plex cystic lesion with peripheral blood flow in the left axilla with and erythema. She reported that the lump worsened with internal debris on longitudinal views using (A) grayscale and (B) shaving, use of deodorant, and other forms of cutaneous color Doppler technique.

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Discussion coidosis, subcutaneous or intramuscular injections, and HS, also known as acne inversa, was first described by a surgical history (3). French anatomist and surgeon named Velpeau in 1839. HS MRI features include marked thickening of the skin and is a member of the follicular occlusion tetrad, which in- induration of the subcutaneous tissues. Lesions have low cludes other conditions such as dissecting cellulitis of the signal intensity on T1-weighted images and high signal on scalp, pilonidal sinus/cysts, and acne conglobata (1, 4). HS T2-weighted and STIR sequences; they typically demon- is estimated to affect approximately 1% of the population strate a rim with multiple abscesses located within the su- and appears to be significantly more common in females, perficial dermis (4). with a ratio of 3:1 (1). HS affects various apocrine-gland- Real-time ultrasound of HS lesions demonstrates dermal rich locations, and certain anatomical locations have a sex- fluid collections of varying sizes and echogenicity, depend- ual predilection. For example, perianal HS affects males ing on the age of the lesion (5). Active lesions can be indis- more often than females (2, 4), and genitofemoral HS is tinguishable from acne and appear as rounded hypoechoic more likely to develop in females. Typically, HS develops structures deep to the dermis, extending to the subcutane- after puberty, most commonly in men and women in their ous tissues (6). Hypoechoic linear bands can sometimes be early 20s, with the prevalence declining after age 50 (1). seen surrounding inflamed lesions in the epidermis and Certain factors, such as smoking and obesity, can increase deeper dermis, most likely representing edema within the the risk and directly affect the severity of HS (1). Approxi- adjacent tissues (6). mately one third of patients also report a family history of While the typical features of HS have been described, HS, with an autosomal dominant mode of inheritance these may be indistinguishable from other inflammatory identified in some families (1). lesions of the dermis and epidermis including carbuncles, The disease process is thought to begin with the occlu- erysipelas (a bacterial infection causing epidermal inflam- sion of a hair follicle secondary to hyperkeratosis. Follicular mation), or cellulitis (dermal inflammation) (4). Other dif- plugging results in occlusion and dilation of the piloseba- ferential considerations include lymphadenitis and infected ceous unit, with subsequent rupture and spillage of its con- Bartholin or sebaceous cysts (4). These entities are distin- tents onto the surrounding dermis. The extruded contents guished from HS by response to treatment, whereas HS consist of corneocytes, bacteria, sebum products, and hair, ultimately fails to respond (1). which together elicit a chemotactic response and resultant Complications of HS may be local or systemic, in that a inflammatory cell infiltrate (2, 4). Neutrophil, lymphocyte, localized infection can lead to septicemia and distant ab- and histiocyte influx results in abscess formation, and even- scesses. The chronic inflammatory nature of the disease tual infection and suppuration lead to sinus and fistula for- can result in permanent areas of scarring and fibrosis with mation (2). Reepithelization of the follicle then occurs, re- strictures developing in the anus, urethra, and rectum; con- sulting in sinus-tract formation and entrapment of foreign tractures and decreased mobility; and (in longstanding material and bacteria (2). The tracts coalesce over time and cases) development of squamous-cell carcinoma (4). can potentially dissect into deeper structures such as mus- In the early stages of the disease, when it is considered cle, lymph nodes, and bowel, depending on location. The localized and includes single or multiple abscesses without apocrine glands become secondarily involved (4), releasing sinus-tract formation or scarring, topical treatment with purulent malodorous material that soils clothing and causes antibiotics and estrogens has shown success by reduction of social embarrassment. Early symptoms of HS include the number of lesions on followup evaluation (1, 5). Clini- burning, pruritis, warmth, hyperhidrosis, and pain. cal experience with intralesional injection of steroids has A limited number of articles in the literature describe the also been helpful, although this method is not well studied imaging features of HS. Overall, the sonographic appear- in the literature (1). With more complex cases of recurring ance of HS can vary in size and shape, but it typically con- abscesses and sinus-tract formation that may be more sists of a dermal fluid collection ranging from simple to widely separated, treatment involves a more systemic ap- complex. To date, imaging features on mammography have proach. Oral antibiotics and anti-inflammatory agents have not been described in the literature. On MRI, features of shown to improve disease severity by 50% and quality of HS that have been described include skin thickening, sub- life significantly in two case series (1). With further progres- cutaneous T1-hypointense lesions that demonstrate hyper- sion of disease severity, there is often diffuse involvement of intensity on fluid-sensitive sequences, and rim- the affected region with formation of interconnecting tracts enhancement postcontrast within apocrine-gland-rich re- and abscesses, resulting in significant cosmetic disfigure- gions (4). One case report also describes HS as being FDG- ment. Several studies have shown that severe cases can avid on PET/CT (3). benefit from treatment with systemic immunosuppressive Imaging features on PET/CT may include multifocal therapy; however, only a few of these studies actually dem- uptake of radiotracer within the superficial subcutaneous onstrate a significant benefit in their outcomes (1). Severe tissues with corresponding skin thickening on the CT com- cases with extensive scarring have also been managed sur- ponent, as described in a case report (3). However, false- gically, often a curative measure. Incision and drainage of positive results in the subcutaneous tissue may occur at sites lesions is discouraged, as lesions are likely to recur (1). Sur- of increased metabolism such as those with infection, sar- gery may consist of a localized excision of the sinus tract and abscess, or a more extensive excision of all hair-

RCR Radiology Case Reports | radiology.casereports.net! 3! 2013 | Volume 8 | Issue 3 Hidradenitis suppurativa: Mammographic and sonographic manifestations in two cases bearing skin in affected areas with or without skin graft/ 3. Simpson RC, Dyer M.J.S ., Entwisle J., Harman KE. flap reconstruction (1, 2). Instances of recurrence occur less Positron emission tomography features of hidradenitis often with more extensive surgical excision. Finally, though suppurativa. Brit J Radiol 2011; 84:e164-e165. [Pub- laser and radiation therapies have been described swith low Med] rates of recurrence, there are only limited comparative 4. Kelly A.M., Cronin P. MRI Features of hidradenitis studies with surgical techniques (1, 7). suppurativa and review of the literature. AJR 2005;185:1201–1204. [PubMed] References 5. Wortsman X, Jemec GBE. Real-time compound imag- ing ultrasound of hidradenitis suppurativa. Dermatol 1. Jemec G.B.E. Hidradenitis suppurativa. N Eng J Med. Surg 2007;33:1340–1342. [PubMed] 2012. 366;158-64. [PubMed] 6. Jemec G.B.E, Gniadecka M. Ultrasound examination 2. Alikhan A., Lynch P.J., Eisen D.B. Hidradenitis suppu- of hair follicles in hidradenitis suppurativa. Arch Derma- rativa: A comprehensive review. J Am Acad Dermatol tol. 1997;133:967-970. [PubMed] 2009;60:539-61. [PubMed] 7. Slade DE, Powell BW, Mortimer PS. Hidradenitis sup- purativa: Pathogenesis and management. Br J Plast Surg 2003; 56:451–461. [PubMed]

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