Hidradenitis suppurativa masquerades as blepharitis

October 16, 2018

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 with this unusual dermatologic pathology.

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 with this unusual dermatologic pathology.

My first patient with hidradenitis suppurativa presented with ulcerative-like lesions along her eyelid margins resembling herpetic blepharitis. Indeed, this was my initial diagnosis until I learned more about hidradenitis suppurativa.

Learning more
Hidradenitis suppurativa, 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 (a narrow opening underneath the skin that can extend in any direction through soft tissue, resulting 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.1 Secondary bacterial infection of these lesions can occur.2

Recall that apocrine glands release their secretions into the hair follicles, rather than directly on to the skin like eccrine sweat glands.

Related: Experts offer top blepharitis tips

Incidence and symptoms
The prevalence of hidradenits suppurative is about 1 percent to 4 percent in Europe but lower in North America.3 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.

Hidradenitis suppurativa commonly starts with mild skin 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.4

The psychosocial effect of HS is devastating because of the associated pain, malodorous discharge, and scarring.5

Prompt recognition and initiation of treatment can reduce the risk of HS progression to debilitating end-stage disease. Treatment options, depending on the presentation and severity of the disease, include topical or oral antibiotics, oral or injection corticosteroids, biologics (Humira [adalimumab, Abbvie], for example), or surgery.

Ocular involvement
Hidradenits suppurative also affects the glands of Moll, also known as ciliary glands, that 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 Moll glands 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 with HA, a case described in 19676 involved discharge from the openings of the cilia and of the glands of Moll along the lash lines of the lids. Treatment for HA-related “blepharitis,” akin to its other dermatologic manifestations, are hygiene and topical treatment with an antibiotic with or without an anti-inflammatory.

Differential diagnosis of discharge emanating from the lash line should also include parasites such as lice and Demodex and staphylococcal blepharitis. In a recently reported case, Demodex overpopulation was associated with a treatment-resistant and persistent course of HA.7

Interestingly, HA has been associated with other inflammatory eye diseases (uveitis, scleritis, peripheral ulcerative keratitis) as well as inflammatory bowel disease (Crohn’s, ulcerative colitis).8

Remember to evaluate the lash line during your anterior segment examinations and be sensitive to dermatology concerns patients may describe in their history because many of these can manifest with ocular pathology.

References:

1. Naasan H, Affleck A. Atypical hidradenitis suppurativa. Clin Exp Dermatol. 2015 Dec;40(8):891-3.
2. Lee EY, Alhusayen R, Lansang P, Shear N, Yeung J. What is hidradenitis suppurativa? Can Fam Physician. 2017 Feb;63(2):114-120.
3. Jemec GB, Heidenheim M, Nielsen NH. The prevalence of hidradenitis suppurativa and its potential precursor lesions. J Am Acad Dermatol. 1996 Aug;35(2 Pt 1):191-4.
4. Alikhan A, Lynch PJ, Eisen DB. Hidradenitis suppurativa: a comprehensive review. J Am Acad Dermatol. 2009 Apr;60(4):539-61.
5. Matusiak Ł, Bieniek A, Szepietowski JC. Hidradenitis suppurativa markedly decreases quality of life and professional activity. J Am Acad Dermatol. 2010 Apr;62(4):706-8, 708.e1.
6. Sachs DD, Gordon AT. Hidradenitis suppurativa of Glands of Moll. Arch Ophthalmol. 1967;77(5):635-636.
7. Ünal E, Güvendi Akçınar U, Arduç A. Hidradenitis Suppurativa, Metabolic Syndrome, and Demodex spp. Infestation. Turkiye Parazitol Derg. 2018 Jun;42(2):171-174.
8. Syed AU, Uzunaslan D, Lowder CY, Srivastava S, Maya JJ, Rula A Hajj-Ali RA.  Hidradenitis Suppuritiva Is Associated with Inflammatory Eye Disease. Arthritis Rheumatol. 2015;67 suppl 10. Available at: https://acrabstracts.org/abstract/hidradenitis-suppuritiva-is-associated-with-inflammatory-eye-disease/. Accessed 10/15/18.

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