A 48-year-old man comes to the office due to recurrent "painful lumps" in both axillae that often rupture spontaneously. He has had these lesions for the past several years, but lately they are recurring more frequently. The discharge from the lesions has an unpleasant smell, and the patient has to use deodorant several times daily. He also takes an over-the-counter nonsteroidal anti-inflammatory drug for pain. The patient has had no fever, chills, cough, anorexia, or weight loss. He has no other medical problems. The patient has not traveled out of his home state of Ohio for the past several years and works as a landscaper in a park. He smokes a pack of cigarettes daily but does not use alcohol or illicit drugs.
Vital signs are within normal limits. BMI is 47 kg/m². The axillary areas have findings as shown below, and the remainder of the physical examination shows no abnormalities.

Which of the following is the most likely diagnosis in this patient?

Question

A 48-year-old man comes to the office due to recurrent "painful lumps" in both axillae that often rupture spontaneously. He has had these lesions for the past several years, but lately they are recurring more frequently. The discharge from the lesions has an unpleasant smell, and the patient has to use deodorant several times daily. He also takes an over-the-counter nonsteroidal anti-inflammatory drug for pain. The patient has had no fever, chills, cough, anorexia, or weight loss. He has no other medical problems. The patient has not traveled out of his home state of Ohio for the past several years and works as a landscaper in a park. He smokes a pack of cigarettes daily but does not use alcohol or illicit drugs.
Vital signs are within normal limits. BMI is 47 kg/m². The axillary areas have findings as shown below, and the remainder of the physical examination shows no abnormalities.

Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec193a_9794_02f9_853d_1fd0de50d7bc_MD0002_00 This patient has hidradenitis suppurativa (HS), a chronic inflammatory disorder characterized by occlusion of folliculopilosebaceous units. It is most common in intertriginous areas (eg, axillae) but can occur in any hair-bearing skin. HS begins as a solitary, painful, inflamed nodule that can last for several days to months before progressing to an abscess with purulent or serosanguineous drainage. The symptoms typically improve after drainage, but recurrent nodules can lead to sinus tracts, comedones, and significant scarring. Risk factors include smoking, obesity, and mechanical stress on the skin (eg, friction, pressure). General measures for HS include weight loss, smoking cessation, and daily skin cleansing of the affected area. Mild disease typically responds to topical clindamycin, but some patients may require intralesional glucocorticoids or oral antibiotics during flare-ups. Moderate disease is characterized by inflammatory nodules, sinus tracts, and scarring (as seen in this patient) and typically requires oral antibiotics (eg, tetracyclines) for several weeks for adequate effect. Severe and refractory disease may require biologic tumor necrosis factor-alpha inhibitors (eg, infliximab), oral retinoids (eg, acitretin), and, occasionally, surgical excision. (Choice A) Blastomycosis is a fungal infection that primarily affects the lungs (pneumonia) but may occasionally cause verrucous skin lesions with heaped-up borders (not nodules or draining lesions). (Choice C) Irritant contact dermatitis is most common in the hands and is characterized by pruritus, erythema, swelling, and sometimes vesicle formation. Chronic symptoms may lead to excoriations, hyperkeratosis, and fissuring, but nodules and sinus tracts in the axilla are more consistent with HS. (Choice D) Folliculitis is characterized by small papules and pustules involving hair follicles. The findings are typically superficial and transient, in contrast to the deep, persistent lesions in this patient. (Choice E) Tuberculous lymphadenitis typically presents as nontender, subacute cervical adenitis. This patient's lesions are chronic and painful and predominantly involve the axillae. Educational objective: Hidradenitis suppurativa is a chronic relapsing disorder that is most common in intertriginous areas. It begins as a solitary, painful nodule that can progress to an abscess with subsequent drainage. The symptoms typically improve after drainage, but recurrent nodules can lead to sinus tracts, comedones, and scarring. __________ References: Hidradenitis suppurativa: A guide for the practicing physician. (http://www.ncbi.nlm.nih.gov/pubmed/26653298)

A 48-Year-Old Man Comes to the Office Due to Recurrent