Atypical hidradenitis suppurativa in caesarean scar site

By Mardi Chapman

26 Jun 2020

A rare case of hidradenitis suppurativa (HS) recurrence has been reported in the caesarean scar of a Queensland woman previously successfully managed on adalimumab.

The woman, who ceased adalimumab at the end of her second trimester, remained free of HS until a week after the caesarean delivery of a healthy, full-term infant.

She then developed painful nodules in her axilla so ceased breastfeeding and recommenced adalimumab.

While her axilla settled, about two months later she developed small nodules and inflammatory tracts around her caesarean scar.

“These were initially thought to represent a fungal infection and were treated with an over the-counter antifungal cream with limited efficacy,” the case report by Brisbane dermatologist Dr Lynda Spelman said.

“She was subsequently treated with topical antimicrobial preparation containing gramicidin, neomycin sulfate, nystatin, and triamcinolone acetonide, followed by oral amoxycillin and clavulanic acid, and potassium permanganate soaks to the area, all of which provided minimal improvement.”

Published in Case Reports in Obstetrics and Gynecology, the report said the woman experienced significant distress at being told that her symptoms were the result of insufficient wound care and recurrent infection of the area.

One month after the onset of symptoms, she presented back to her regular dermatology practice with a number of small, well-defined HS lesions, with nodules and discharging sinus tracts around the caesarean scar.

“Her disease elsewhere remained silent, and her compliance with Humira was excellent. She was subsequently diagnosed with a recurrence of HS in her caesarean scar, providing her with a sense of relief following the multiple previous presentations and reviews.”

The HS slowly responded over 12 months to treatment with doxycycline 100 mg daily and Prontosan Wound Gel and Wash (polyaminopropyl biguanide (polihexanide), betaine surfactant) in addition to Humira.

“Our extensive search of the literature reveals only one other case of a recurrence of HS in a caesarean scar,” the case report said.

However reports of HS developing in otherwise normal skin exposed to injury or trauma, and especially associated with obesity, are more common.

The case report said that most women experience no change in their HS during pregnancy, with 20% reporting improvement while pregnant, and 8% experiencing worsening of their disease.

However, “Given that HS is more likely to affect women and can be seen from the age of puberty, a knowledge of the management of HS during pregnancy and breast feeding forms an essential part of the holistic management of the HS patient.”

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