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DRY EYE DX AND TX

IDENTIFYING HIDRADENITIS SUPPURATIVA

A recent patient’s medical history revealed that he suffered from hidradenitis suppurativa (HS). This was not the first time that I encountered a patient who had this unusual dermatologic pathology. The first patient presented with ulcerative-like lesions on her eyelid resembling herpetic blepharitis. Indeed, this was my initial diagnosis until I learned a little more about HS.

What Is Hidradenitis Suppurativa?

HS, also known as acne inversa, is a chronic, recurrent, and debilitating skin condition. It is a relapsing inflammatory disease resulting in subcutaneous abscesses, sinus tracts (narrow openings or passageways beneath the skin that can extend in any direction through soft tissue and result in dead space with potential for abscess formation), and scarring, arising predominantly in apocrine gland-bearing skin. The sites affected, in order of frequency, are the axillae, groin, perianal and perineal region, mammary and submammary skin, buttocks, and pubic region.

Other sites that may be affected more rarely include the chest, scalp, retroauricular and preauricular skin, thighs, abdomen, and eyelids. As the disease advances, areas exposed to repetitive mechanical stress, such as the nape of the neck, trunk, and waistband area, can also be affected (Naasan and Afleck, 2015). Secondary bacterial infection of these lesions can occur (Lee et al, 2017).

Recall that apocrine glands release their secretions into the hair follicles, rather than directly onto the skin as eccrine sweat glands do. Apocrine sweat glands are usually larger compared to eccrine glands, develop in hair follicles, have secretory tubes lined by a single layer of cells, and slowly produce secretions that contain many organic substances.

The prevalence of HS is about 1% to 4% in Europe but is lower in North America (Jemec et al, 1996). HS is more common in females, with a female-to-male ratio of 4:1. The age of onset is usually after puberty and before the age of 40, peaking in the second and third decades of life.

The onset of HS is insidious, starting with mild discomfort, erythema, burning, pruritus, and hyperhidrosis. It progresses to form tender or deep-seated nodules that expand and coalesce to form large painful abscesses. The rupture of these abscesses releases malodorous and purulent discharge (Alikhan et al, 2009).

The psychosocial effect of HS is devastating because of the associated pain, malodorous discharge, and scarring (Matusiak et al, 2010). In patients who have HS, early lesions mimic other skin conditions and thus are often misdiagnosed as recurrent furunculosis or boils. The delay in HS diagnosis can be 12 years or longer (Mebazaa et al, 2009). Prompt recognition and initiation of treatment can reduce the risk of HS progression to debilitating end-stage disease.

HS and the Eye

HS also affects the glands of Moll, also known as ciliary glands, which are modified apocrine sweat glands found on the margin of the eyelid. They are next to the base of the eyelashes and anterior to the meibomian glands. The glands of Moll generally open into the follicles of the eyelashes, into the ducts of Zeiss glands, or directly into the skin of the lids along the same line as the cilia.

As in my first case of a patient who had HS, a case described by Sachs and Gordon in 1967 involved discharge from the openings of the cilia and of the glands of Moll along the lash lines of the lids.

Differential diagnosis of discharge emanating from the lash line should also include parasites such as lice, Demodex, and staphylococcal blepharitis. Remember to evaluate the lash line during your anterior segment examinations and that many dermatological conditions can manifest with ocular pathology. CLS

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