What Is Causing These Painful "Boils"?

Mary P. Maiberger, MD
Julia Schwartz, MD

A 42-year-old African American male presented to our dermatology clinic for draining “boils” in his underarms and groin area for the past 2 years. He had undergone various treatments by his primary care physician, including repeated rounds of oral antibiotics and incision and drainage of the most bothersome lesions. He was a smoker and had a history of hypertension and hypercholesterolemia. He denied any family history of any skin conditions. He was currently unemployed. Given excessive drainage and pain from his skin condition, the patient was depressed and infrequently left the house, due to concerns over the odor and difficulty in sitting or walking for long periods with his groin involvement.

Physical examination and diagnostic tests:

On physical examination, the patient appeared slightly overweight. He demonstrated several erythematous, tender, draining abscesses in his bilateral axillae and inguinal creases in a linear fashion with some scarring and tethering of the axillary skin (Figure). Blood-tinged, purulent discharge was noted on the bandage covering his wounds. 

Laboratory work was notable for an elevated erythrocyte sedimentation rate (ESR) and mild microcytic anemia. Other laboratory work-up was within normal limits.

The patient was given a diagnosis of hidradenitis suppurativa on the basis of his history, clinical examination findings, and laboratory work-up.

Discussion:

Hidradenitis suppurativa (HS) is a chronic, inflammatory disease of the folliculosebaceous unit. This disease is characterized by recurrent painful, draining nodules and cysts that eventually lead to scar and fistula formation in intertriginous areas such as the axilla, groin, and buttocks.1 Patients often present with a chief complaint of “boils.” HS has a female predominance of 3 to 1 and may be more prevalent in patients of African descent.1,2 Like other inflammatory skin conditions, such as psoriasis, HS is not just skin deep. Recent evidence has demonstrated that there is a disproportionately high comorbidity burden on patients with HS.2

The concurrent use of tobacco in patients with HS has been well established in the literature. Patients with HS are significantly more likely to be smokers or have a history of smoking compared with controls.1–3 Furthermore, it has been shown that cessation of smoking has led to improvement of HS severity, and, therefore, counselling on smoking cessation should be a priority in the management of this disease.4

HS patients are significantly more likely to be obese than their control counterparts. When controlled for other comorbidities, patients with HS had a more than 2-fold higher odds of obesity than age-, sex-, and race-matched controls.2 Additionally, obesity has been attributed to higher severity of disease; hence, lifestyle modifications that promote weight loss should be encouraged in these patients.5 When controlled for all other comorbidities, HS patients also possess an increased odds of having hypertension, diabetes, and dyslipidemia.2 Unsurprisingly, the prevalence of metabolic syndrome in patients with HS has been estimated as high as 50%.6

HS has also been linked to systemic inflammatory conditions such as inflammatory bowel disease and various arthropathies, endocrinopathies such as polycystic ovarian syndrome and thyroid disease, malignancies such as squamous cell carcinoma and lymphoma, and psychological comorbidities such as depression.2,7,8 With such a wide range of associated comorbidities, it should not come as a surprise that hospitalizations and emergency room use is significantly higher in patients with HS compared to those with psoriasis and controls.9

Patients with HS often suffer from other medical comorbidities. Regardless of where these patients initially present for their skin disease, a multidisciplinary approach that includes dermatology, primary care, and even subspecialties such as rheumatology, endocrinology and psychiatry/psychology, should be employed in the treatment of these potentially underserved individuals.

Outcome of our case:

Our patient was started on a regimen of good physical hygiene, including washing with an antibacterial soap, wearing loose fitting clothing, and applying soaks to his active lesions. He was encouraged to adopt lifestyle modifications, including cessation of smoking and weight loss. He was referred to psychiatry to help manage the impact of the disease on his quality of life. After failing multiple rounds of protracted oral antibiotics, the patient was begun on subcutaneous adalimumab, 40 mg, weekly. Over several months, he noted reduced draining of his lesions and a decrease in overall lesion activity. 

References:

  1. Danby FW, Margesson LJ. Hidradenitis suppurativa. Dermatol Clin. 2010;28(4):779-793. doi:10.1016/j.det.2010.07.003.
  2. Shlyankevich J, Chen AJ, Kim GE, Kimball AB. Hidradenitis suppurativa is a systemic disease with substantial comorbidity burden: a chart-verified case-control analysis. J Am Acad Dermatol. 2014;71(6):1144-1150. doi:10.1016/j.jaad.2014.09.012.
  3. Sartorius K, Emtestam L, Jemec GBE, Lapins J. Objective scoring of hidradenitis suppurativa reflecting the role of tobacco smoking and obesity. Br J Dermatol. 2009;161(4):831-839. doi:10.1111/j.1365-2133.2009.09198.x.
  4. Kromann CB, Deckers IE, Esmann S, Boer J, Prens EP, Jemec GBE. Risk factors, clinical course and long-term prognosis in hidradenitis suppurativa: a cross-sectional study. Br J Dermatol. 2014;171(4):819-824. doi:10.1111/bjd.13090.
  5. Canoui-Poitrine F, Revuz JE, Wolkenstein P, et al. Clinical characteristics of a series of 302 French patients with hidradenitis suppurativa, with an analysis of factors associated with disease severity. J Am Acad Dermatol. 2009;61(1):51-57. doi:10.1016/j.jaad.2009.02.013.
  6. Gold DA, Reeder VJ, Mahan MG, et al. The prevalence of metabolic syndrome in patients with hidradenitis suppurativa. J Am Acad Dermatol. 2014;70(4):699-703. doi:10.1016/j.jaad.2013.11.014.
  7. van der Zee HH, de Winter K, van der Woude CJ, Prens EP. The prevalence of hidradenitis suppurativa in 1093 patients with inflammatory bowel disease. Br J Dermatol. 2014;171(3):673-675. doi:10.1111/bjd.13002.
  8. Kurek A, Johanne Peters EM, Sabat R, Sterry W, Schneider-Burrus S. Depression bei Patienten mit Acne inversa - eine häufige Komorbidität. JDDG J der Dtsch Dermatologischen Gesellschaft. 2013;11(8):743-750. doi:10.1111/ddg.12067_suppl.
  9. Kirby JS, Miller JJ, Adams DR, Leslie D. Health care utilization patterns and costs for patients with hidradenitis suppurativa. JAMA dermatology. 2014;150(9):937-944. doi:10.1001/jamadermatol.2014.691.