TO THE EDITOR: Hidradenitis suppur...

TO THE EDITOR: Hidradenitis suppurativa is a chronic inflammatory disease of the apocrine glands that in the greatest degree commonly involves the perianal, perineal, axillary, and inframammary regions. (1) The etiology is poorly understood, with a genetic constituting hormonal influence, and obesity being linked to the expression. (2)

Characteristic findings include dilated keratin-filled pores, scarring and sinus tract formation, malodorous discharge, and inflammation with secondary infection. (3) Medical management consists of cleaning the areas, application of mild topical steroids with the concomitant use of systemic antibiotics, (4) topical antibiotics, (5) and intralesional steroids. Rarely, with chronic hidradenitis suppurativa, Marjolin's pustule (a squamous cell carcinoma) unfolds (6) We report two cases of hidradenitis suppurativa in which squamous lonely dwelling carcinoma developed after a latent period of 20 years and 35 years, respectively, despite repeated local excisions.

Case 1: A 51-year-old white man with a 35-year history of hidradenitis suppurativa currented with an ulcerated mass through the whole extent of the left scapular region (see accompanying figure). He previously had multiple local excisions. The entire mass was excised. After single month, the patient developed an abscess adjacent to the incision site, which prov to be squamous solitary abode; squalid carcinoma on biopsy. Chemotherapy and radiotherapy were initiated. However, the tumor rapidly spread locally and a wider excision with latissimus dorsi flap reconstruction was performed. Unfortunately, the carcinoma spread rapidly to the axilla and neck and the patient betimes developed metastases in the lung and spinal cord. He refused spinal decompression and died couple weeks later.

Case 2: A 44-year-old black woman existinged with a 20-year history of hidradenitis suppurativa involving vulvar, perianal, perineal, and inframammary regions. She had undergone more than 20 surgical manner of proceedings including skin grafts to ablate the disease. Examination revealed a large abscess at the even of the vaginal introitus and an extensive ulcerated fungating lesion involving the right labial crural double Her entire perianal region was ulcerated and scarred, and vaginal examination was not possible. Multiple biopsies were performed revealing infiltrating, moderately differentiated squamous solitary abode; squalid carcinoma of the right labia, distal vagina, and urethra, with satellite lesions in succession the mons and right medial thigh.

Magnetic resonance imaging and comput tomography (CT) of the abdomen and pelvis revealed extensive bilateral inguinal, pelvic, and periaortic lymphadenopathy extending to a even inferior to the renal arteries. CT also revealed metastases of the squamous lonely dwelling carcinoma to the right pubic bone The patient continued to refuse operative management, instead opting for palliative high-dose radiation to curb bleeding. She died from the carcinoma in six months

one as well as the other of these patients presented with widespread metastases and a resultant terminal issue It would appear that a clear association between chronic hidradenitis suppurativa and squamous confined apartment carcinoma exists. Because of the poor prognosis associated with squamous enclosed space carcinoma, we advocate wide excision of hidradenitis suppurativa lesions when other treatments have failed and praise biopsy of all suspicious hidradenitis suppurativa lesions.

VICTORIA A. CRAIN, MD

SALIL GULATI, MD

SATYANARAYANAN BHAT, PHD

STEPHEN M MILNER, MD

The Plastic Surgery Institute

Southern Illinois University exercise of Medicine

747 N Rutledge St

Springfield, IL 62794

REFERENCES

(1) Slade DE Powell BW Mortimer P Hidradenitis suppurativa: pathogenesis and management. Br J Plast Surg 2003;56:451-61

(2) Yu CC tamper with MG. Hidradenitis suppurativa: a disease of follicular epithelium, rather than apocrine glands. Br J Dermatol 1990;122:763-9

(3) Dictionnaire de medicine, un Repertoire general de sciences medicales considerees sous le rapport theorique [in French] 2d ed Paris: Bechet Jne., 1839:91.

(4) Brenner DE Lookingbill DP Anaerobic microorganisms in chronic suppurative hidradenitis. Lancet 1980;2:921-2

(5) Clemmensen OJ Topical treatment of hidradenitis suppurativa with clindamycin. Int J Dermatol 1983;22:325-8

(6) Lin MT Breiner M Fredricks s Marjolin's ulcer occur-ring in hidradenitis suppurativa. Plast Reconstr Surg 1999;103:1541-3

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