A 28-year-old woman comes to the office due to painful nodular lesions under her arms for the past month. She has also noticed a foul odor. The patient had similar lesions 4 months ago. Other medical conditions include recurrent urinary tract infections. She takes postcoital nitrofurantoin prophylaxis and uses combined oral contraceptives for birth control. The patient smokes a pack of cigarettes daily. Temperature is 36.1 C (97 F), blood pressure is 111/77 mm Hg, and pulse is 78/min. Skin examination shows tender, fluctuant nodules with thick bands of scar tissue at the axillae bilaterally, as shown in the exhibit. Which of the following is the greatest risk factor for this patient's skin condition?

Question

A 28-year-old woman comes to the office due to painful nodular lesions under her arms for the past month.  She has also noticed a foul odor.  The patient had similar lesions 4 months ago.  Other medical conditions include recurrent urinary tract infections.  She takes postcoital nitrofurantoin prophylaxis and uses combined oral contraceptives for birth control.  The patient smokes a pack of cigarettes daily.  Temperature is 36.1 C (97 F), blood pressure is 111/77 mm Hg, and pulse is 78/min.  Skin examination shows tender, fluctuant nodules with thick bands of scar tissue at the axillae bilaterally, as shown in the exhibit.  Which of the following is the greatest risk factor for this patient's skin condition?

Quizplus · Accepted Answer

11ec25c8_d8b2_dc58_bc81_27b9187511c8_MD0003_00 This patient with recurrent, painful nodules and thick, scarred plaques in the axillae has hidradenitis suppurativa (HS). The pathogenesis of HS begins with the occlusion of folliculopilosebaceous units caused by keratinocyte hyperproliferation and abnormal keratinocyte differentiation. Mechanical stress (eg, friction in intertriginous areas) initiates an inflammatory response that can lead to follicular rupture and the release of additional proinflammatory factors. Exacerbated by immune dysregulation and subsequent bacterial colonization or infection, the initial inflammation often evolves into a chronic inflammatory response with a characteristic persistent/relapsing course. A strong association exists between HS and tobacco use. Nicotine and other tobacco components are thought to stimulate follicular occlusion through their effect on keratinocytes. In addition, these substances have proinflammatory effects on neutrophils and T lymphocytes and promote the production of tumor necrosis factor-alpha by keratinocytes. Smoking cessation is typically advised as part of management of HS and improvement of the overall health of the patient. In addition to medical therapy (eg, antibiotics), surgery may be needed for refractory disease and management of sinus tracts and scars. (Choice A) Androgens are thought to stimulate HS development. Combined oral contraceptives containing estrogen have antiandrogenic effects and are used as adjunctive therapy with antibiotics in HS management. (Choice B) Fragrances and other chemicals in deodorants and other personal care products can cause allergic contact dermatitis, which manifests acutely as pruritic, erythematous plaques and vesicles or chronically as scaling and lichenification. Painful, fluctuant nodules with scars are not characteristic. plaques and vesicles scaling and lichenification (Choice C) Although HS is not directly due to infection of the follicle, colonization by a broad range of pathogens may exacerbate the inflammatory response. Long-term antibiotic therapy (eg, oral doxycycline, topical clindamycin) is used to reduce the bacterial load and may have additional anti-inflammatory effects. However, nitrofurantoin is rapidly cleared and concentrated in the urine and is unlikely to influence the development of HS. (Choice D) Follicular injury due to excessive friction and mechanical pressure promotes the development of HS and explains its propensity to affect intertriginous areas. However, poor body hygiene does not cause HS. Educational objective: Hidradenitis suppurativa (HS) is a chronic, relapsing condition characterized by inflammatory occlusion of folliculopilosebaceous units. There is a strong association between tobacco use and HS. References: Hidradenitis suppurativa: rapid evidence review. (http://www.ncbi.nlm.nih.gov/pubmed/31674740)

A 28-Year-Old Woman Comes to the Office Due to Painful