Infectious Eccrine Hidradenitis Associated With Intense Sun Exposure Charlotte Hwa Vuong, MD; Ruth Walters, MD; Jennifer A. Stein, MD, PhD Practice Points Neutrophilic eccrine hidradenitis is a response to nonspecific stimuli in a wide spectrum of clinical settings. Infectious eccrine hidradenitis should be included in the differential diagnosis in patients who develop an erythematous papular eruption after sunburn. Infectious eccrine hidradenitis (IEH), which usu- erythematous papules on the flanks, grouped pap- ally manifests as singular or multiple erythema- ules and pustules on the back, and papules on the tous papules or plaques, is a rare dermatosis legs in areas of resolving sunburn (Figure 1). It involving an infectious agent and histologic find- was her first sun exposure of the season, and the ings identical to that of CUTISneutrophilic eccrine patient previously had used the same sunscreen, hidradenitis (NEH). We report a case of IEH in which she applied on all parts of her body. Her cur- a 24-year-old woman who developed a pruritic, rent medications included desogestrel and ethinyl erythematous, papular rash after a sunburn. A estradiol, naratriptan hydrochloride, and loratadine culture of a pustule revealed methicillin-sensitive and pseudoephedrine. Staphylococcus aureus. Our patient had complete Histology showed a superficial and deep peri- resolution of her rash within 2 weeks of starting vascular infiltrate of lymphocytes, histiocytes, and amoxicillinDo and clavulanate. ThisNot case of IEH and neutrophils Copy with prominent neutrophilic infiltration NEH related to both intense sun exposure and of eccrine glands (Figure 2). In the overlying epider- infection supports the hypothesis that NEH is a mis, there was focal parakeratosis with a collection of response to nonspecific stimuli and may occur in neutrophils and an aggregate of gram-positive cocci. many different clinical settings. Special stains for fungi and acid-fast bacilli failed Cutis. 2013;92:40-45. to reveal microorganisms. A culture from a sample pustule revealed moderate growth of methicillin- Case Report sensitive Staphylococcus aureus. The patient was A 24-year-old white woman with no remarkable started on amoxicillin and clavulanate (500 mg/ medical history developed a sunburn during a record- 125 mg twice daily for 7 days) and the rash began breaking heat wave in New York, New York.1 As to improve. It completely cleared within 2 weeks. the sunburn was resolving a week later, a pruritic, Routine health maintenance examinations were erythematous, papular rash appeared on her upper normal at 1-year follow-up. back. She presented with a linear distribution of Comment Neutrophilic eccrine hidradenitis (NEH) is a rare From the Ronald O. Perelman Department of Dermatology, New York benign dermatosis that involves an inflammatory University School of Medicine, New York. reaction of the eccrine glands.2 Clinically, it usually The authors report no conflict of interest. appears as singular or multiple erythematous papules Correspondence: Jennifer A. Stein, MD, PhD, Ronald O. Perelman 3 Department of Dermatology, New York University School of or plaques that typically are asymptomatic. Pustules Medicine, 560 First Ave, H-100, New York, NY 10016 can occur in isolation or in erythematous plaques. ([email protected]). The lesions may develop anywhere on the body, 40 CUTIS® WWW.CUTIS.COM Copyright Cutis 2013. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Infectious Eccrine Hidradenitis A A CUTIS B B Figure 1. Linear distribution of erythematous papules on the lateral abdomen and flanks (A). Grouped papules and Figure 2. A punch biopsy specimen demonstrated a few pustules on the back (B). superficial and deep perivascular and periadnexal infil- trate of lymphocytes, histiocytes, and neutrophils (A)(H&E, Do Notoriginal magnificationCopy 40). Note the prominent neutro- though the groin and axillae typically are spared. philic infiltration of eccrine glands associated with foci of Histologic findings include a neutrophilic infiltrate vacuolar degeneration of secretory epithelium (B)(H&E, around and within eccrine glands associated with original magnification 400). necrosis of eccrine epithelium.3 Neutrophilic eccrine hidradenitis was initially drugs, including acetaminophen9 and granulocyte described and is most commonly seen in patients colony-stimulating factor.10,11 undergoing chemotherapy for acute myelogenous Infectious agents rarely have been cultured from leukemia but has since been described in patients lesions in patients with NEH; these cases consti- with Hodgkin disease, non-Hodgkin lymphoma, tute what is known as infectious eccrine hidrad- chronic lymphocytic leukemia, osteosarcoma, and enitis (IEH)(Table).12-18 Although histologically other solid tumors. Most patients who develop NEH identical,13 NEH and IEH are treated differently, received chemotherapy treatment with cytarabine as NEH usually resolves spontaneously while IEH and anthracyclines prior to the onset of lesions, often requires treatment with antibiotics.15 In 1985, though other chemotherapeutic agents also have Moreno et al12 reported the first known case of IEH, been implicated.3 However, NEH also can herald in which Serratia was cultured from recurrent cutane- the onset of hematologic malignancies such as acute ous lesions in a 48-year-old man with chronic renal myelogenous leukemia4 and chronic myelogenous failure who was undergoing hemodialysis. Histology leukemia.5 Although 90% of NEH cases develop in of the lesions was typical of NEH. Treatment with patients with malignancies,3 the disease also has been antiseptic soaps provided no benefit; the authors reported in patients with human immunodeficiency did not report that antibiotics were offered as treat- virus6-8 and those taking nonchemotherapeutic ment.12 The second known case of IEH was described WWW.CUTIS.COM VOLUME 92, JULY 2013 41 Copyright Cutis 2013. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Infectious Eccrine Hidradenitis 42 CUTIS Cases of Infectious Eccrine Hidradenitis ® Associated Medical Reference Conditions and Tissue Blood (Year) Age/Sex Medications Culture Culture Clinical Findings Treatment Outcome Moreno 48 y/M Glomerulonephritis; patient Serratia N/A Erythematous 6-mm Antiseptic Spontaneous et al12 was on hemodialysis papules on upper and soaps resolution (1985) lower extremities and within 3 mo but mild pruritus, recurrent recurrent each CUTIS each year year; antiseptic soaps provided no benefit Allegue 49 y/M Flulike symptoms Enterobacter N/A Erythematous, Intramuscular Lesions resolved et al13 cloacae from violaceous, 5- to amikacin in 1 wk without (1990) pustule 15-mm papules and (500 mg recurrence Do Not Copypustules on upper twice daily) and lower extremities and abdomen Taira and 47 y/M Following heart Staphylococcus N/A Recurrent, 3- to Dicloxacillin Lesions resolved Gerber2 transplant 4 years prior aureus 4-mm, edematous, within 5 d (1992) on cyclosporine erythematous papules on upper arm Combemale 31 y/M Following surgery for Serratia Negative Recurrent Ciprofloxacin; Lesions in et al14 ependymoma: febrile, marcescens erythematous papules amoxicillin and remission after (2000) urinary tract infection due on lower extremities clavulanate, and each round of to Escherichia coli with and abdomen ciprofloxacin; antibiotic therapy recurrent ependymoma and ceftriaxone and new urinary tract infection due tetracyclines to Klebsiella pneumoniae WWW.CUTIS.COM Copyright Cutis 2013. 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WWW.CUTIS.COM Associated Medical Reference Conditions and Tissue Blood (Year) Age/Sex Medications Culture Culture Clinical Findings Treatment Outcome Antonovich 83 y/F COPD, mitral valve Nocardia Nocardia Tender erythematous Trimethoprim- Lesions resolved et al15 prolapse, breast and asteroides asteroides plaques and nodules sulfamethoxazole in 3 wk (2004) endometrial cancer, on right lower leg endocarditis; medications: tamoxifen, prednisone, pulmonaryCUTIS inhalers Shih 6–14 mo/ None Coagulase- N/A Urticarial-like Oral antibiotics Lesions resolved et al16 6 M and 4 F negative erythematous plaques (not specified) within 3 wk (2005) staphylococci and nodules on extremities Oono 71 y/F Bullous pemphigoid while Negative but N/A Erythematous None Lesions resolved et al17 on prednisolone Gram stain of infiltrated papules in 2 wk (2006)Do Notskin biopsyCopy on chest, upper back, showed gram- and extremities with positive cocci small pustules and in lumen of mild pruritus spiral course of affected eccrine ducts Takai and 23 y/M Streptococcal Negative Group A Tender, erythematous, Antibiotics (not Lesions resolved Infectious Eccrine Hidradenitis Matsunaga18 infectious endocarditis streptococci 1- to 3-cm papules and specified) and after operation (2006) plaques on trunk and valvoplasty for and antibiotic extremities endocarditis injection Current 24 y/F Sunburn Staphylococcus N/A Erythematous papules Amoxicillin and VOLUME 92, JULY 2013 Lesions resolved report aureus from and pustules on trunk clavulanate in 2 wk (2010) pustule and lower extremities with pruritus Abbreviations: M, male; N/A, not available; F, female; COPD, chronic obstructive pulmonary disease. 43 Copyright Cutis 2013. 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