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. RCR Radiology Case Reports | radiology.casereports.net! 2! 2013 | Volume 8 | Issue 3 Hidradenitis suppurativa: Mammographic and sonographic manifestations in two cases 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