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Bacteriology of Hidradenitis Suppurativa 11 Chapter 11 Bacteriology of Hidradenitis Suppurativa 11 Cristina Oprica, Carl Erik Nord Key points Q Antibiotics do not cure the disease but they may relieve the symptoms through Q The pathogenesis of hidradenitis either an antibacterial or an anti- suppurativa (HS) is still poorly under- inflammatory effect stood and not yet clearly defined Q A large variety of bacteria can be found in HS lesions and many of them belong to the normal flora of the skin #ONTENTS 11.1 Normal Microflora of the Skin ...........86 Q In the studies using the bacteria prevalent on the surface of the lesions 11.2 BacteriaFoundinHSLesions ...........87 there is possible contamination from 11.3 General Factors About Bacterial the resident flora of the skin InvolvementinHSPathogenicity ........90 11.4 The Role of Antibiotics in the Treatment 11 Q In cases of cultures obtained from the of HS ..................................91 deeper parts of HS, Staphylococcus 11.5 Possible Consequences aureus, coagulase-negative staphylo- forBacterialEcologydue cocci and anaerobic bacteria have toAntibioticTreatmentinHS ...........92 commonly been isolated References .............................92 Q The first event seems to be follicular occlusion by keratinized stratified 11.1 Normal Microflora of the Skin squamous epithelium in apocrine- bearing areas, with subsequent inflam- Normal human skin is colonized by a large vari- mation ety of organisms that live as commensals on its surface. There are quantitative differences Q The initial inflammatory change can be among different regions of the skin, related to produced by a pyogenic bacterial temperature difference, moisture content, and infection or by factors similar to those the presence of various amounts of skin lipids involved in acne that may be inhibitory or lethal for some micro- organisms. These differences characterize three Q In chronic lesions, bacteria represent a main regions of the skin: (1) axilla, perineum, risk factor for the destructive scarring and toe webs; (2) hands, face, and trunk; and (3) and extension of the disease and arms and legs [20]. The skin microflora reside secondary bacterial infections may on the skin surface and in the ducts of hair fol- occur licles and sebaceous glands [38]. Bacteriology of Hidradenitis Suppurativa Chapter 11 87 Table 11.1. The most important genera and species of bacteria normally found on the skin Genus Characteristics Most prevalent species Coagulase-negative Aerobic, Gram-positive cocci S. hominis, S. haemolyticus Staphylococcus S. epidermidis Micrococcus Aerobic, Gram-positive cocci M. luteus, M. varians Corynebacterium Aerobic, Gram-positive pleomorphic rods C. bovis, C. minutissimum Propionibacterium Anaerobic, Gram-positive rods P. acnes, P. granulosum, P. avidum Acinetobacter Aerobic, Gram-negative coccobacilli A .calcoaceticus var. lwoffi and var. anitratus The sites affected by HS are, in order of fre- Propionibacteria are Gram-positive rod- quency: axillary, inguinal, perianal and perine- shaped anaerobic bacteria. Propionibacterium al, mammary and inframammary, buttock, pu- acnes and Propionibacterium granulosum are bic region, chest, scalp, retroauricular, and the associated with follicles that have large seba- eyelid [50]. ceous glands on the face and upper trunk and The major groups of microorganisms present they have a role in acne pathogenesis. Propioni- on the skin are various genera of bacteria and bacterium avidum is found in moist areas (axil- yeasts. The predominant bacteria of the skin are lae and groin) and it is not known if it has patho- as follows (Table 11.1) [20, 21]: genic potential [21]. Acinetobacter species are the only important Q Coagulase-negative staphylococci Gram-negative residents of the skin and are Q Micrococci found in the axillae and groin of 25% of the Q Saprophytic Corynebacterium species population [21]. (diphtheroids) In addition, any bacterial species that is found Q Propionibacterium species in nature or belongs to the normal flora on non- Q Acinetobacter species. cutaneous areas may temporarily be found on the skin [47]. Staphylococcus aureus is not nor- Various coagulase-negative staphylococci are mally considered a resident of normal skin, but found on the skin and some have special predi- it can be found on perineal skin, axillae, and in lection for some areas, for example Staphylococ- the toe cleft. Hemolytic streptococci may be cus hominis and Staphylococcus haemolyticus found as transients on different skin sites, more are found principally in areas where there are often in children [38]. Atypical mycobacteria numerous apocrine glands, such as axillae and may be found in genital and axillary regions the pubic region [20, 32]. Staphylococcus epider- and Bacillus species or different Gram-negative midis is also an important resident, colonizing bacilli such as Proteus, Pseudomonas, Entero- moist areas of the skin [21]. It is found preferen- bacter and Klebsiella are rarely found on the tially in the upper part of the body and repre- skin [20, 38]. sents over 50% of the resident staphylococci In conclusion, a large variety of bacteria are [47]. able to colonize the most affected areas in HS: Micrococcus species are found on the skin, axilla, perineum, and the groin. especially in women and children, and Micro- coccus luteus and Micrococcus varians are the prevailing species [20, 21]. These microorgan- 11.2 Bacteria Found in HS Lesions isms often colonize axilla, perineum, and groin [21]. Although the HS etiology is unknown, a large Different bacteria belonging to the genus variety of microorganisms can be isolated from Corynebacterium are associated, but not exclu- the lesions. The clinical picture of the disease sively, with moist areas of the skin [21]. resembles an infectious process and various 88 Cristina Oprica, Carl Erik Nord Table 11.2. Studies describing the diversity of bacteria found in various HS lesions Investigator Bacteria found Area of the skin Leach et al. [35] Staphylococcus aureus, anaerobic bacteria Axillae Brenner and Lookingbill [7] Staphylococcus aureus, Staphylococcus epidermidis Perirectal, groin, axillae Bacteroides fragilis, Bacteroides melaninogenicus Highet et al. [23] Streptococcus milleri Perineal Highet et al. [24] Streptococcus milleri, Staphylococcus aureus, Perineal anaerobic streptococci, Bacteroides species Finegold et al. [18] Biophila wadsworthia Axillae Bendahan et al. [5] Chlamydia trachomatis Perineal Jemec et al. [29] Staphylococcus aureus, Streptococcus milleri, Axillae, groin, breasts, Staphylococcus epidermidis, Staphylococcus hominis buttocks Brook and Frazier [8] Staphylococcus aureus, Streptococcus pyogenes, Axillae Pseudomonas aeruginosa; Peptostreptococcus species, Prevotella species, micro-aerophilic streptococci, Fusobacterium species, Bacteroides species Lapins et al. [33] Staphylococcus aureus, coagulase-negative Axillae and perineal staphylococci, enterococci, group B hemolytic streptococci, group C hemolytic streptococci, Bacillus cereus, diphtheroides, enterobacteriacae-; Peptostreptococcus species, Propionibacterium acnes, microaerophilic streptococci, Lactobacillus species, Bacteroides fragilis, other Bacteroides species, Prevotella species 11 bacteria are suspected as being responsible for streptococci, Fusobacterium species, and Bacte- the inflammation. The bacterial findings are roides species. considered by some authors as either contami- In most of the studies samples are collected nants from the normal skin flora or a result of from the surface of the lesions [22–24] and there secondary infection in a previously sterile pro- is a high risk of contamination with the resident cess [33]. skin flora. In these conditions the bacteriologi- Despite the volume of the discharge the HS cal results are difficult to interpret. Jemec et al. lesions are often found to be sterile [29, 33], but [29] have aspirated pus from the deeper parts of sometimes a large variety of microorganisms HS. Bacteria were found in half of active lesions: can be isolated from the sinuses, particularly Staphylococcus aureus and coagulase-negative staphylococci, streptococci, Gram-negative rods, staphylococci (Staphylococcus epidermidis and and anaerobic bacteria (Table 11.2). The bacte- Staphylococcus hominis) were most commonly rial flora are not consistent and may change un- isolated. An explanation for the large number of predictably [31]. Brook and Frazier [8] found, in negative cultures could be that it is difficult to a retrospective review of clinical and bacterio- localize the infected part using the aspiration logical data from patients with axillary disease, technique. It was found that the duration of the that the most prevalent aerobic bacteria were disease was shorter for those patients in whom Staphylococcus aureus, Streptococcus pyogenes, Staphylococcus aureus was detected as a possible and Pseudomonas aeruginosa and the most fre- etiological factor, indicating that this bacterium quent anaerobic bacteria were Peptostreptococ- may be involved early in the disease pathogene- cus species, Prevotella species, microaerophilic sis by causing anatomical changes in the hair Bacteriology of Hidradenitis Suppurativa Chapter 11 89 Table 11.3. Possible factors responsible for coagulase- crease the pathogenic properties of these other- negative staphylococci pathogenicity in HS lesions wise harmless members of the normal flora. Factors Effect Lapins et al. [33] have often found coagulase- negative staphylococci as the sole bacteria in the deep portion of the lesions and
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