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Indian Journal of Dermatology
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CORRESPONDENCE
Year : 2020  |  Volume : 65  |  Issue : 3  |  Page : 231-232
Atypical hidradenitis suppurativa on the leg in a psoriatic patient


1 Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
2 Isesaki Municipal Hospital, Isesaki, Gunma, Japan

Date of Web Publication14-Apr-2020

Correspondence Address:
Masahito Yasuda
Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.IJD_20_18

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How to cite this article:
Yasuda M, Shimizu A, Tamura A, Ishikawa O. Atypical hidradenitis suppurativa on the leg in a psoriatic patient. Indian J Dermatol 2020;65:231-2

How to cite this URL:
Yasuda M, Shimizu A, Tamura A, Ishikawa O. Atypical hidradenitis suppurativa on the leg in a psoriatic patient. Indian J Dermatol [serial online] 2020 [cited 2020 Nov 27];65:231-2. Available from: https://www.e-ijd.org/text.asp?2020/65/3/231/282443




Sir,

Hidradenitis suppurativa (HS), also called acne inversa, is a chronic follicular occlusive pyoderma that typically affects the intertriginous regions, e. g., the axilla, groin, and perianal regions. Recently, HS has been subdivided into three types: “typical axillary mammary,” “follicular,” and “gluteal.”[1] Herein, we report a case of atypical HS of the follicular type that developed on the leg of a patient with psoriasis vulgaris.

A 54-year-old Japanese man presented with a 7-month history of painful nodules and ulcers with recurrent discharging sinuses on the right leg. He was diagnosed with psoriasis vulgaris at the age of 52 year and diabetes mellitus at 53 year of age. He had smoked 40 packs/year until he was 40 year of age. His body mass index (BMI) was 21.5 kg/m2. The lesion was treated elsewhere through drainage of the abscesses. Since the lesions did not improve, he visited our hospital. A physical examination revealed reddish-brown indurated plaques with ulcers and fistulae and active purulent discharge on the front of the right leg [Figure 1]a. He also had typical psoriatic lesions on the trunk and extremities [Figure 1]b. We diagnosed these ulcers and fistulae as atypical HS. He had no family history of HS and psoriasis. Bacterial culture revealed a small number of coagulase-negative Staphylococcus and Streptococcus anginosus. We performed debridement and split-thickness mesh skin grafting. Histological examination revealed sinuses lined with epidermis in the dermis [Figure 1]d and dense infiltration of mononuclear cells, including plasma cells, around the sinuses [Figure 1]e. No HS recurrence had occurred throughout the 10-year follow-up [Figure 1]c.
Figure 1: Physical examination shows (a) purulent fistulae on the right leg and (b) psoriatic erythema on the left leg before the operation and (c) grafting scar 10 years after the operation. Histological examinations show (d) sinus lined with epidermis in the dermis (H and E, ×40) and (e) infiltration of mononuclear cells, including plasma cells, around the sinuses (H and E, ×200)

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There have been a few studies about concomitant psoriasis and HS. von Laffert et al. analyzed 128 patients with HS in Germany and reported that the prevalence of psoriasis vulgaris was 3.9% (5/128) in these patients.[2] Meanwhile, Patel et al. analyzed 56 patients with both HS and psoriasis and reported that more patients with both HS and psoriasis were current smokers and had a higher BMI compared to patients with only psoriasis.[3] Recently, psoriasis and HS have been suggested to co-exist along a spectrum of autoinflammatory diseases, such as pyoderma gangrenosum, acne, psoriasis, arthritis, and suppurative hidradenitis syndrome.[4] Tumor necrosis factor (TNF)-α has been considered to be an important factor in the pathogenesis, since anti-TNF-α antibodies are effective in treating autoinflammatory diseases. However, we speculated that our patient's condition was not an autoinflammatory syndrome since neither severe acne nor arthritis was present. Tanaka et al. also reported the case of a psoriatic patient with atypical HS in the lower leg, thereby suggesting that mechanical stimuli due to obesity and follicular occlusions due to psoriatic lesions might have induced HS.[5] Some factors, such as mechanical stimuli, might be responsible for both psoriasis and HS on the leg by the activation of a TNF-α cascade.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that his name and initial will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Canoui-Poitrine F, Le Thuaut A, Revuz JE, Viallette C, Gabison G, Poli F, et al. Identification of three hidradenitis suppurativa phenotypes: Latent class analysis of a cross-sectional study. J Invest Dermatol 2013;133:1506-11.  Back to cited text no. 1
    
2.
von Laffert M, Stadie V, Wohlrab J, Marsch WC. Hidradenitis suppurativa/acne inversa: Bilocated epithelial hyperplasia with very different sequelae. Br J Dermatol 2011;164:367-71.  Back to cited text no. 2
    
3.
Patel M, Cohen JM, Wright NA, Merola JF, Qureshi AA, Vleugels RA, et al. Epidemiology of concomitant psoriasis and hidradenitis suppurativa: Experience of a tertiary medical center. J Am Acad Dermatol 2015;73:701-2.  Back to cited text no. 3
    
4.
Garzorz N, Papanagiotou V, Atenhan A, Andres C, Eyerich S, Eyerich K, et al. Pyoderma gangrenosum, acne, psoriasis, arthritis and suppurative hidradenitis (PAPASH)-syndrome: A new entity within the spectrum of autoinflammatory syndromes? J Eur Acad Dermatol Venerol 2016;30:141-3.  Back to cited text no. 4
    
5.
Tanaka A, Goto Y, Iwade M, Uhara H, Okuyama R. Rapid progression of hidradenitis suppurativa in the lower leg of a patient with psoriasis vulgaris. Acta Derm Venereol 2012;92:105-6.  Back to cited text no. 5
    


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