A 24-year-old woman comes to the office due to painful bumps in her groin. She has had these before, and they typically resolve within a few weeks, sometimes after draining spontaneously. Now the bumps occur more frequently and last longer, and sitting has become painful. The patient has no chronic medical conditions or prior surgeries. Temperature is 36.7 C (98 F). BMI is 35 kg/m². Physical examination is shown below: Which of the following is the most likely diagnosis in this patient?

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11ec25c8_d9c2_292f_bc81_b1c04aa75235_MD0003_00 This patient has hidradenitis suppurativa, a chronic inflammatory condition that involves recurrent occlusion of hair follicles in intertriginous regions (eg, groin, axilla). Hidradenitis suppurativa commonly develops in women age 20-40; risk factors include obesity, tobacco use, and family history. Hidradenitis suppurativa often initially presents as a solitary, painful nodule surrounding a follicle that can persist up to several months and eventually develops into a spontaneously draining abscess. This disease has a chronic, progressive course with recurrences that affect follicles within the same region. Patients have multiple lesions with subsequent inflammation and abscess drainage that eventually develop into sinus tract and scar formation (eg, fibrotic bands, acneiform scars, thickened plaques), as seen in this patient. The diagnosis is made clinically, and treatment is aimed at reducing frequency of lesions and preventing disease progression and complications (eg, contractures, lymphatic obstruction, fistula). (Choice A) Genital herpes infection causes recurrent painful lesions; however, these lesions do not drain and are not classically associated with fibrosis or plaque formation. In addition, in contrast to this patient, those with recurrent genital herpes typically have less frequent and less painful lesions over time. (Choice B) Granuloma inguinale is a sexually transmitted infection caused by Klebsiella granulomatis that typically presents with painless, red ulcers with no associated inguinal lymphadenopathy-not seen in this patient. (Choice D) Lymphogranuloma venereum (LGV) is a sexually transmitted infection caused by Chlamydia trachomatis serovars L1-3. Patients can have painful inguinal lymphadenopathy (ie, buboes) that can cause scarring and strictures within the inguinal region. However, LGV does not cause recurrent infection, making this diagnosis less likely. (Choice E) Vulvar lichen sclerosus can cause scarring and distortion; however, it is typically limited to the vaginal introitus and vulva rather than found throughout the inguinal region. In addition, there are no associated nodules or draining from the lesion. Educational objective: Hidradenitis suppurativa is a chronic inflammatory condition typically found in intertriginous areas (eg, inguinal region). The lesions occur due to occluded follicles that cause painful nodules and abscesses that can develop into draining sinus tracts and result in significant scarring. References: Hidradenitis suppurativa. (http://www.ncbi.nlm.nih.gov/pubmed/25214437) Pathophysiology of hidradenitis suppurativa: an update. (http://www.ncbi.nlm.nih.gov/pubmed/26470623)

A 24-Year-Old Woman Comes to the Office Due to Painful