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Clin Colon Rectal Surg 2011; 24(1): 071-080
DOI: 10.1055/s-0031-1272826
© Thieme Medical Publishers

Hidradenitis Suppurativa and Pruritus Ani

Theodor Asgeirsson1 , Robert Nunoo2 , Martin A. Luchtefeld3
  • 1Department of Surgery, Spectrum Health, Greenville, Michigan
  • 2Department of Research, Spectrum Health, Grand Rapids, Michigan
  • 3Division of Colon and Rectal Surgery, Spectrum Health, Grand Rapids, Michigan
Further Information

Publication History

Publication Date:
23 February 2011 (online)

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ABSTRACT

Hidradenitis suppurativa (HS) is a chronic debilitating disorder that can affect any areas bearing apocrine glands. Perineal HS is associated with high morbidity compared with other anatomic regions. Early-stage disease may mimic various other forms of cutaneous disorders, but as HS progresses pathognomonic skin changes occur. Clinical stage can guide the therapeutic approach, but the lowest recurrence rate is obtained by removing all involved skin and subcutaneous fat. Pruritus ani is a complex disease with a multitude of etiologies. Its management can be frustrating and disappointing for the patient and doctor alike. The key is to start with simple treatment options focusing on perianal hygiene and avoidance of the most common offending foods and beverages. If these measures fail, topical medications should be attempted before graduating to perianal injections of methylene blue as a last resort.

KEYWORDS

Hidradenitis suppurativa - acne inversa - pruritus ani

REFERENCES

  • 1 Singer M, Cintron J R. Hidradentis suppuratuva.  Clin Colon Rectal Surg. 2002;  14 233-242
    Article in Thieme ConnectPubMedGoogle Scholar
  • 2 Anderson Jr M J, Dockerty M B. Perianal hidradenitis suppurativa; a clinical and pathologic study.  Dis Colon Rectum. 1958;  1 (1) 23-31
    CrossrefPubMedGoogle Scholar
  • 3 Shelley W B, Levy E J, Weidman F D. Apocrine sweat retention in man. III. Apocrine retention cysts.  AMA Arch Derm. 1955;  72 (2) 171-172
    PubMedGoogle Scholar
  • 4 Yu C C, Cook M G. Hidradenitis suppurativa: a disease of follicular epithelium, rather than apocrine glands.  Br J Dermatol. 1990;  122 (6) 763-769
    CrossrefPubMedGoogle Scholar
  • 5 Anderson B B, Cadogan C A, Gangadharam D. Hidradenitis suppurativa of the perineum, scrotum, and gluteal area: presentation, complications, and treatment.  J Natl Med Assoc. 1982;  74 (10) 999-1003
    PubMedGoogle Scholar
  • 6 von der Werth J M, Jemec G B. Morbidity in patients with hidradenitis suppurativa.  Br J Dermatol. 2001;  144 (4) 809-813
    CrossrefPubMedGoogle Scholar
  • 7 Clemmensen O J. Topical treatment of hidradenitis suppurativa with clindamycin.  Int J Dermatol. 1983;  22 (5) 325-328
    CrossrefPubMedGoogle Scholar
  • 8 Mortimer P S, Dawber R P, Gales M A, Moore R A. Mediation of hidradenitis suppurativa by androgens.  Br Med J (Clin Res Ed). 1986;  292 (6515) 245-248
    CrossrefPubMedGoogle Scholar
  • 9 Rose R F, Goodfield M J, Clark S M. Treatment of recalcitrant hidradenitis suppurativa with oral cyclosporin.  Clin Exp Dermatol. 2006;  31 (1) 154-155
    CrossrefPubMedGoogle Scholar
  • 10 Rompel R. [Orientation guides for excision lines and flap design].  J Dtsch Dermatol Ges. 2006;  4 (10) 888-890
    PubMedGoogle Scholar
  • 11 Revuz J E, Canoui-Poitrine F, Wolkenstein P et al.. Prevalence and factors associated with hidradenitis suppurativa: results from two case-control studies.  J Am Acad Dermatol. 2008;  59 (4) 596-601
    CrossrefPubMedGoogle Scholar
  • 12 Jemec G B, Ganslandt C, Ortonne J P et al.. A new scalp formulation of calcipotriene plus betamethasone compared with its active ingredients and the vehicle in the treatment of scalp psoriasis: a randomized, double-blind, controlled trial.  J Am Acad Dermatol. 2008;  59 (3) 455-463
    CrossrefPubMedGoogle Scholar
  • 13 Wiltz O, Schoetz Jr D J, Murray J J, Roberts P L, Coller J A, Veidenheimer M C. Perianal hidradenitis suppurativa. The Lahey Clinic experience.  Dis Colon Rectum. 1990;  33 (9) 731-734
    CrossrefPubMedGoogle Scholar
  • 14 Homma H. On apocrine seat glands in white and Negro men and women.  Bull Johns Hopkins Hosp. 1926;  38 365-371
    PubMedGoogle Scholar
  • 15 Paletta C, Jurkiewicz M J. Hidradenitis suppurativa.  Clin Plast Surg. 1987;  14 (2) 383-390
    PubMedGoogle Scholar
  • 16 Velpeau A. Un repertoire general des sciences medicales sous la rapport theorique et practique.  Dictionnaire de Medecine. 1839;  2 (2) 91-109
    PubMedGoogle Scholar
  • 17 Verneuil A. De l'hidrosadenite phlegmoneuse et des asbces sudoripares.  Arch Gen Med. 1864;  2 537-557
    PubMedGoogle Scholar
  • 18 Jemec G B, Heidenheim M, Nielsen N H. Hidradenitis suppurativa—characteristics and consequences.  Clin Exp Dermatol. 1996;  21 (6) 419-423
    CrossrefPubMedGoogle Scholar
  • 19 Bendahan J, Paran H, Kolman S, Neufeld D M, Freund U. The possible role of Chlamydia trachomatis in perineal suppurative hidradenitis.  Eur J Surg. 1992;  158 (4) 213-215
    PubMedGoogle Scholar
  • 20 Highet A S, Warren R E, Weekes A J. Bacteriology and antibiotic treatment of perineal suppurative hidradenitis.  Arch Dermatol. 1988;  124 (7) 1047-1051
    CrossrefPubMedGoogle Scholar
  • 21 Harrison B J, Read G F, Hughes L E. Endocrine basis for the clinical presentation of hidradenitis suppurativa.  Br J Surg. 1988;  75 (10) 972-975
    CrossrefPubMedGoogle Scholar
  • 22 Jemec G B. The symptomatology of hidradenitis suppurativa in women.  Br J Dermatol. 1988;  119 (3) 345-350
    CrossrefPubMedGoogle Scholar
  • 23 Morgan W P, Leicester G. The role of depilation and deodorants in hidradenitis suppurativa.  Arch Dermatol. 1982;  118 (2) 101-102
    CrossrefPubMedGoogle Scholar
  • 24 Attanoos R L, Appleton M A, Douglas-Jones A G. The pathogenesis of hidradenitis suppurativa: a closer look at apocrine and apoeccrine glands.  Br J Dermatol. 1995;  133 (2) 254-258
    CrossrefPubMedGoogle Scholar
  • 25 Hana A, Booken D, Henrich C et al.. Functional significance of non-neuronal acetylcholine in skin epithelia.  Life Sci. 2007;  80 (24-25) 2214-2220
    CrossrefPubMedGoogle Scholar
  • 26 Parks R W, Parks T G. Pathogenesis, clinical features and management of hidradenitis suppurativa.  Ann R Coll Surg Engl. 1997;  79 (2) 83-89
    PubMedGoogle Scholar
  • 27 Lapins J, Asman B, Gustafsson A, Bergström K, Emtestam L. Neutrophil-related host response in hidradenitis suppurativa: a pilot study in patients with inactive disease.  Acta Derm Venereol. 2001;  81 (2) 96-99
    CrossrefPubMedGoogle Scholar
  • 28 Hunger R E, Surovy A M, Hassan A S, Braathen L R, Yawalkar N. Toll-like receptor 2 is highly expressed in lesions of acne inversa and colocalizes with C-type lectin receptor.  Br J Dermatol. 2008;  158 (4) 691-697
    CrossrefPubMedGoogle Scholar
  • 29 Giamarellos-Bourboulis E J, Pelekanou E, Antonopoulou A et al.. An open-label phase II study of the safety and efficacy of etanercept for the therapy of hidradenitis suppurativa.  Br J Dermatol. 2008;  158 (3) 567-572
    PubMedGoogle Scholar
  • 30 Banerjee A K. Surgical treatment of hidradenitis suppurativa.  Br J Surg. 1992;  79 (9) 863-866
    CrossrefPubMedGoogle Scholar
  • 31 Thornton J P, Abcarian H. Surgical treatment of perianal and perineal hidradenitis suppurativa.  Dis Colon Rectum. 1978;  21 (8) 573-577
    CrossrefPubMedGoogle Scholar
  • 32 Culp C E. Chronic hidradenitis suppurativa of the anal canal. A surgical skin disease.  Dis Colon Rectum. 1983;  26 (10) 669-676
    CrossrefPubMedGoogle Scholar
  • 33 Church J M, Fazio V W, Lavery I C, Oakley J R, Milsom J W. The differential diagnosis and comorbidity of hidradenitis suppurativa and perianal Crohn's disease.  Int J Colorectal Dis. 1993;  8 (3) 117-119
    CrossrefPubMedGoogle Scholar
  • 34 Randall K, Roenigk H H. Dermatologic Surgery, Principles and Practice. New York: Marcel Dekker; 1989
    Google Scholar
  • 35 Sartorius K, Lapins J, Emtestam L, Jemec G B. Suggestions for uniform outcome variables when reporting treatment effects in hidradenitis suppurativa.  Br J Dermatol. 2003;  149 (1) 211-213
    CrossrefPubMedGoogle Scholar
  • 36 Alikhan A, Lynch P J, Eisen D B. Hidradenitis suppurativa: a comprehensive review.  J Am Acad Dermatol. 2009;  60 (4) 539-561 quiz 562-563
    CrossrefPubMedGoogle Scholar
  • 37 Pérez-Diaz D, Calvo-Serrano M, Mártinez-Hijosa E et al.. Squamous cell carcinoma complicating perianal hidradenitis suppurativa.  Int J Colorectal Dis. 1995;  10 (4) 225-228
    CrossrefPubMedGoogle Scholar
  • 38 Anstey A V, Wilkinson J D, Lord P. Squamous cell carcinoma complicating hidradenitis suppurativa.  Br J Dermatol. 1990;  123 (4) 527-531
    PubMedGoogle Scholar
  • 39 Radcliffe K W. Hidradenitis suppurativa.  Genitourin Med. 1991;  67 (1) 58
    PubMedGoogle Scholar
  • 40 Williams S T, Busby R C, DeMuth R J, Nelson H. Perineal hidradenitis suppurativa: presentation of two unusual complications and a review.  Ann Plast Surg. 1991;  26 (5) 456-462
    CrossrefPubMedGoogle Scholar
  • 41 Konety B R, Cooper T, Flood H D, Futrell J W. Scrotal elephantiasis associated with hidradenitis suppurativa.  Plast Reconstr Surg. 1996;  97 (6) 1243-1245
    CrossrefPubMedGoogle Scholar
  • 42 Krbec A C. Current understanding and management of hidradenitis suppurativa.  J Am Acad Nurse Pract. 2007;  19 (5) 228-234
    CrossrefPubMedGoogle Scholar
  • 43 Mendonça H, Rebelo C, Fernandes A, Lino A, Garcia e Silva L. Squamous cell carcinoma arising in hidradenitis suppurativa.  J Dermatol Surg Oncol. 1991;  17 (10) 830-832
    PubMedGoogle Scholar
  • 44 Brown C F, Gallup D G, Brown V M. Hidradenitis suppurativa of the anogenital region: response to isotretinoin.  Am J Obstet Gynecol. 1988;  158 (1) 12-15
    PubMedGoogle Scholar
  • 45 Boer J, van Gemert M J. Long-term results of isotretinoin in the treatment of 68 patients with hidradenitis suppurativa.  J Am Acad Dermatol. 1999;  40 (1) 73-76
    CrossrefPubMedGoogle Scholar
  • 46 Joseph M A, Jayaseelan E, Ganapathi B, Stephen J. Hidradenitis suppurativa treated with finasteride.  J Dermatolog Treat. 2005;  16 (2) 75-78
    CrossrefPubMedGoogle Scholar
  • 47 Buckley D A, Rogers S. Cyclosporin-responsive hidradenitis suppurativa.  J R Soc Med. 1995;  88 (5) 289P-290P
    PubMedGoogle Scholar
  • 48 Bolanowski A, Mannon R B, Holland S M et al.. Successful renal transplantation in patients with chronic granulomatous disease.  Am J Transplant. 2006;  6 (3) 636-639
    CrossrefPubMedGoogle Scholar
  • 49 Sullivan T P, Welsh E, Kerdel F A, Burdick A E, Kirsner R S. Infliximab for hidradenitis suppurativa.  Br J Dermatol. 2003;  149 (5) 1046-1049
    CrossrefPubMedGoogle Scholar
  • 50 Cusack C, Buckley C. Etanercept: effective in the management of hidradenitis suppurativa.  Br J Dermatol. 2006;  154 (4) 726-729
    PubMedGoogle Scholar
  • 51 Zeligman I. Temporary x-ray epilation therapy of chronic axillary hidradenitis suppurativa.  Arch Dermatol. 1965;  92 (6) 690-694
    CrossrefPubMedGoogle Scholar
  • 52 Lapins J, Sartorius K, Emtestam L. Scanner-assisted carbon dioxide laser surgery: a retrospective follow-up study of patients with hidradenitis suppurativa.  J Am Acad Dermatol. 2002;  47 (2) 280-285
    CrossrefPubMedGoogle Scholar
  • 53 Bong J L, Shalders K, Saihan E. Treatment of persistent painful nodules of hidradenitis suppurativa with cryotherapy.  Clin Exp Dermatol. 2003;  28 (3) 241-244
    CrossrefPubMedGoogle Scholar
  • 54 Ritz J P, Runkel N, Haier J, Buhr H J. Extent of surgery and recurrence rate of hidradenitis suppurativa.  Int J Colorectal Dis. 1998;  13 (4) 164-168
    CrossrefPubMedGoogle Scholar
  • 55 Brown S C, Kazzazi N, Lord P H. Surgical treatment of perineal hidradenitis suppurativa with special reference to recognition of the perianal form.  Br J Surg. 1986;  73 (12) 978-980
    CrossrefPubMedGoogle Scholar
  • 56 Watson J D. Hidradenitis suppurativa—a clinical review.  Br J Plast Surg. 1985;  38 (4) 567-569
    CrossrefPubMedGoogle Scholar
  • 57 Harrison B J, Kumar S, Read G F, Edwards C A, Scanlon M F, Hughes L E. Hidradenitis suppurativa: evidence for an endocrine abnormality.  Br J Surg. 1985;  72 (12) 1002-1004
    CrossrefPubMedGoogle Scholar
  • 58 Kagan R J, Yakuboff K P, Warner P, Warden G D. Surgical treatment of hidradenitis suppurativa: a 10-year experience.  Surgery. 2005;  138 (4) 734-740 discussion 740-741
    CrossrefPubMedGoogle Scholar
  • 59 Ramasastry S S, Conklin W T, Granick M S, Futrell J W. Surgical management of massive perianal hidradenitis suppurativa.  Ann Plast Surg. 1985;  15 (3) 218-223
    CrossrefPubMedGoogle Scholar
  • 60 Solanki N S, Roshan A, Malata C M. Pedicled gracilis myocutaneous flap for treatment of recalcitrant hidradenitis suppurativa of the groin and perineum.  J Wound Care. 2009;  18 (3) 111-112
    PubMedGoogle Scholar
  • 61 Rompel R, Petres J. Long-term results of wide surgical excision in 106 patients with hidradenitis suppurativa.  Dermatol Surg. 2000;  26 (7) 638-643
    CrossrefPubMedGoogle Scholar
  • 62 Markell K W, Billingham R P. Pruritus ani: etiology and management.  Surg Clin North Am. 2010;  90 (1) 125-135
    CrossrefPubMedGoogle Scholar
  • 63 Siddiqi S, Vijay V, Ward M, Mahendran R, Warren S. Pruritus ani.  Ann R Coll Surg Engl. 2008;  90 (6) 457-463
    CrossrefPubMedGoogle Scholar
  • 64 Stermer E, Sukhotnic I, Shaoul R. Pruritus ani: an approach to an itching condition.  J Pediatr Gastroenterol Nutr. 2009;  48 (5) 513-516
    CrossrefPubMedGoogle Scholar
  • 64a Vincent C. Anorectal pain and irritation: anal fissure, levator syndrome, proctalgia fugax and pruritus ani.  Prim Care. 1999;  26 (1) 53-68
    CrossrefPubMedGoogle Scholar
  • 65 Lacy B E, Weiser K. Common anorectal disorders: diagnosis and treatment.  Curr Gastroenterol Rep. 2009;  11 (5) 413-419
    CrossrefPubMedGoogle Scholar
  • 66 Kränke B, Trummer M, Brabek E, Komericki P, Turek T D, Aberer W. Etiologic and causative factors in perianal dermatitis: results of a prospective study in 126 patients.  Wien Klin Wochenschr. 2006;  118 (3-4) 90-94
    CrossrefPubMedGoogle Scholar
  • 67 Jongen J, Eberstein A, Peleikis H G, Kahlke V, Herbst R A. Perianal streptococcal dermatitis: an important differential diagnosis in pediatric patients.  Dis Colon Rectum. 2008;  51 (5) 584-587
    CrossrefPubMedGoogle Scholar
  • 68 Singh S P, Panda C, Rout N, Mishra A P. Anal albendazole application for pruritus ani in threadworm infestation.  J Trop Pediatr. 2005;  51 (6) 386
    CrossrefPubMedGoogle Scholar
  • 69 Caplan R M. The irritant role of feces in the genesis of perianal itch.  Gastroenterology. 1966;  50 (1) 19-23
    PubMedGoogle Scholar
  • 70 Smith L E, Henrichs D, McCullah R D. Prospective studies on the etiology and treatment of pruritus ani.  Dis Colon Rectum. 1982;  25 (4) 358-363
    CrossrefPubMedGoogle Scholar
  • 71 McKenna K E. Allergic contact dermatitis from glyceryl trinitrate ointment.  Contact Dermat. 2000;  42 (4) 246
    PubMedGoogle Scholar
  • 72 Hejna M, Valencak J, Raderer M. Anal pruritus after cancer chemotherapy with gemcitabine.  N Engl J Med. 1999;  340 (8) 655-656
    CrossrefPubMedGoogle Scholar
  • 73 Pfenninger J L, Zainea G G. Common anorectal conditions. Part I. Symptoms and complaints.  Am Fam Physician. 2001;  63 (12) 2391-2398
    PubMedGoogle Scholar
  • 74 Kuehn H G, Gebbensleben O, Hilger Y, Rohde H. Relationship between anal symptoms and anal findings.  Int J Med Sci. 2009;  6 (2) 77-84
    PubMedGoogle Scholar
  • 75 Zuccati G, Lotti T, Mastrolorenzo A, Rapaccini A, Tiradritti L. Pruritus ani.  Dermatol Ther. 2005;  18 (4) 355-362
    CrossrefPubMedGoogle Scholar
  • 76 Weichert G E. An approach to the treatment of anogenital pruritus.  Dermatol Ther. 2004;  17 (1) 129-133
    CrossrefPubMedGoogle Scholar
  • 77 Dasan S, Neill S M, Donaldson D R, Scott H J. Treatment of persistent pruritus ani in a combined colorectal and dermatological clinic.  Br J Surg. 1999;  86 (10) 1337-1340
    CrossrefPubMedGoogle Scholar
  • 78 Handa Y, Watanabe O, Adachi A, Yamanaka N. Squamous cell carcinoma of the anal margin with pruritus ani of long duration.  Dermatol Surg. 2003;  29 (1) 108-110
    CrossrefPubMedGoogle Scholar
  • 79 Mazier W P. Hemorrhoids, fissures, and pruritus ani.  Surg Clin North Am. 1994;  74 (6) 1277-1292
    PubMedGoogle Scholar
  • 80 Gopal D V. Diseases of the rectum and anus: a clinical approach to common disorders.  Clin Cornerstone. 2002;  4 (4) 34-48
    CrossrefPubMedGoogle Scholar
  • 81 Al-Ghnaniem R, Short K, Pullen A, Fuller L C, Rennie J A, Leather A J. 1% hydrocortisone ointment is an effective treatment of pruritus ani: a pilot randomized controlled crossover trial.  Int J Colorectal Dis. 2007;  22 (12) 1463-1467
    CrossrefPubMedGoogle Scholar
  • 82 Oztaş M O, Oztaş P, Onder M. Idiopathic perianal pruritus: washing compared with topical corticosteroids.  Postgrad Med J. 2004;  80 (943) 295-297
    CrossrefPubMedGoogle Scholar
  • 83 Lysy J, Sistiery-Ittah M, Israelit Y et al.. Topical capsaicin—a novel and effective treatment for idiopathic intractable pruritus ani: a randomised, placebo controlled, crossover study.  Gut. 2003;  52 (9) 1323-1326
    CrossrefPubMedGoogle Scholar
  • 84 Mentes B B, Akin M, Leventoglu S, Gultekin F A, Oguz M. Intradermal methylene blue injection for the treatment of intractable idiopathic pruritus ani: results of 30 cases.  Tech Coloproctol. 2004;  8 (1) 11-14
    CrossrefPubMedGoogle Scholar
  • 85 Sutherland A D, Faragher I G, Frizelle F A. Intradermal injection of methylene blue for the treatment of refractory pruritus ani.  Colorectal Dis. 2009;  11 (3) 282-287
    CrossrefPubMedGoogle Scholar
  • 86 Botterill I D, Sagar P M. Intra-dermal methylene blue, hydrocortisone and lignocaine for chronic, intractable pruritus ani.  Colorectal Dis. 2002;  4 (2) 144-146
    CrossrefPubMedGoogle Scholar
  • 87 Rucklidge J J, Saunders D. Hypnosis in a case of long-standing idiopathic itch.  Psychosom Med. 1999;  61 (3) 355-358
    PubMedGoogle Scholar

Martin A LuchtefeldM.D. 

Division of Colon and Rectal Surgery, Spectrum Health

4100 Lake Dr. SE, Ste 205, Grand Rapids, MI 49546

Email: Mluchtefeld@gmail.com

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