bubble_chart Overview

After infection of the sweat glands, recurrent episodes occur in the skin and subcutaneous tissues, spreading extensively and forming chronic inflammation, small abscesses, complex sinuses, and fistulas over a wide area, known as suppurative hidrosadenitis. The affected areas are mostly in regions with profuse sweat glands, such as the armpits, anus, genitals, buttocks, thighs, groin, areola, navel, and external ear canal. When occurring around the anus, it is called perianal suppurative hidrosadenitis. In Chinese medicine, it falls under the categories of "honeycomb fistula disease" or "buttock fistula." People aged 20–40 who are obese and prone to profuse sweating are more susceptible to this condition, with women affected more often than men. If left untreated for a long time, the disease may become malignant, typically occurring 10–20 years after onset. According to Jackman's report abroad, among 125 cases of perianal suppurative hidrosadenitis, four developed into squamous cell carcinoma, with an incidence rate of 3.2%.

bubble_chart Pathological Changes

Traditional Chinese medicine believes that this disease is mostly caused by deficiency of healthy qi, invasion of dampness-heat, which descends and accumulates around the anus, leading to stagnation and unresolved conditions; or deficiency of both the heart and spleen, resulting in impaired transportation and transformation, leading to internal production of phlegm-dampness, which gathers at the anus and triggers the disease.

Modern medicine considers the etiology of this disease to be complex, possibly related to factors such as hormonal imbalances, poor embryonic development, local moisture, excessive smoking, and bacterial infections. Bacteria invade sweat glands, hair follicles, and their connected ducts, rapidly multiply, release toxins, and cause inflammation, edema, obstruction, and suppuration in the glandular ducts, spreading subcutaneously to form multiple abscesses. The narrow passages interconnect, leading to recurrent infections. The pathogens are mostly Staphylococcus aureus, streptococci, anaerobic bacteria, and anaerobic streptococci. The bacterial infections in this disease follow certain patterns: the axillary region is mainly affected by Staphylococcus aureus and anaerobic bacteria, especially Gram-negative cocci; the perineal region is primarily affected by anaerobic streptococci; and the anus and genitalia are mainly infected by group F streptococci.

Sweat glands, sebaceous glands, and the hair follicles where their openings are located are all developmentally controlled by androgens. Secretion begins during puberty, peaking during periods of sexual activity. After menopause in women, sweat glands gradually atrophy, and their secretory function significantly weakens. The onset of this disease is entirely consistent with the activity of sweat glands—it never occurs before puberty and ceases after menopause. There is a documented case of a eunuch developing this disease after androgen use. Therefore, both physiologically and pathologically, this disease is considered androgen-dependent.

Poor local hygiene, excessive sweating, smoking, scratching, friction, and other irritants can easily induce this disease.

bubble_chart Clinical Manifestations

Hidradenitis suppurativa typically manifests symptoms after puberty, often occurring in healthy young adults with oily skin and frequent acne. Initially, it presents as single or multiple inflammatory cord-like nodules, pustules, or boils of varying sizes in the sacroperineal or scrotal regions, located subcutaneously or intradermally, corresponding to sweat glands and hair follicles. Later, suppuration leads to ulceration, fistula formation, marked redness and swelling, spontaneous pain, and the discharge of foul-smelling, paste-like purulent secretions. However, the lesions remain confined to the subcutaneous tissue and do not penetrate the internal sphincter. As the first sinus forms, many sinuses develop successively, merging into patches, with extensive subcutaneous necrosis, skin ulceration, and potential spread to the perianal area, scrotum, labia, sacrococcygeal region, buttocks, waist, and thighs. Healing often results in sclerosis and scar formation. Fever, general malaise, painful and swollen lymph nodes, and pilonidal fistulas around the anus are common. In advanced stages, symptoms such as emaciation, anemia, or complications like endocrine and lipid metabolism disorders may occur.

bubble_chart Diagnosis

The skin in areas with profuse sweating exhibits long-term recurrent multiple nodules, lasting for at least 3 months, not necessarily expelling pus or having a fluctuant sensation. However, these gradually spread extensively, forming numerous superficial subcutaneous fistulas, sinuses, and small abscesses. The fistulas and anal canal often show no obvious connection, with no lesions in the anorectal region and no internal opening of anal fistula, but there is a tendency for cord-like fusion. The presence of acne in non-profuse sweating areas, such as behind the ears, is a marker for early diagnosis of this condition, and symptoms often worsen before menstruation. This disease is highly prone to misdiagnosis and must be differentiated from the following conditions:

(1) Furuncle: Distinct follicular infiltration, conical in shape, with a pustular plug at the apex after rupture. The course is short, and there is no specific predilection site.

(2) Lymphadenitis: The nodules are larger and firmer, with deeper inflammatory infiltration, and there are nearby infectious foci.

(3) Complex anal fistula: The tracts are deeper, containing granulation tissue, often with an internal opening, and there is usually a history of anorectal abscess.

(4) Pilonidal sinus: Almost always located in the posterior part of the perineal raphe, and in many cases, hair can be seen in the purulent discharge.

(5) Teratoma: The fistula is very deep, often leading to a distinct abscess cavity.

bubble_chart Treatment Measures

(1) Internal treatment:

1.Chinese medicinals for oral administration:

(1) Excess-heat type: Local redness, swelling, and obvious pain, profuse discharge, dry stool accumulation, scanty dark urine, red tongue texture, yellow and dry coating, surging and rapid pulse. Treatment should focus on clearing heat and removing toxin, subduing swelling and dissipating bind. Prescriptions such as Immortal Formula Life-Saving Decoction or Five-Ingredient Toxin-Eliminating Decoction with modifications can be used.

(2) Phlegm-dampness type: Obesity, cough with profuse phlegm, local erosion, profuse discharge, swollen and pale tongue, white and greasy coating, soggy and slippery pulse. Treatment should focus on drying dampness and dispelling phlegm. Prescriptions such as Two Old Ingredients Decoction combined with Three-Kernel Decoction with modifications can be used.

(3) Heart-spleen deficiency type: Prolonged illness with weak constitution, pale complexion, palpitation and shortness of breath, fatigue and weakness, reluctance to speak due to qi deficiency, poor appetite, dull skin color, loose stools, granulation tissue that is not fresh, pus discharge varying in amount, pale tongue texture, thin white coating, thin and weak pulse. Treatment should focus on nourishing the heart and spleen, removing toxin and dispelling dampness. Prescriptions such as Returning to Spleen Decoction with additions like Forsythia, Atractylodes Rhizome, Phelloendron Bark, and Glabrous Greenbrier can be used.

2. Anti-infection treatment: During the acute phase, antibiotics may be used as appropriate. Generally, the choice of antibiotics is determined based on bacterial culture and drug sensitivity tests. Commonly used drugs include penicillin, erythromycin, doxycycline, vancomycin, etc. However, due to the recurrent nature of the disease and fibrosis around the lesion, antibiotics may not easily penetrate, so drug sensitivity test results may not always align with clinical efficacy.

3. Application of adrenal corticosteroids: Drugs such as prednisolone and dexamethasone can control inflammation but should not be used long-term.

4. Anti-androgen treatment: Recent studies have shown that the anti-androgen drug cyproterone acetate (CPA) has achieved good results in treating suppurative hidradenitis.

(2) External treatment:

1. Use decoctions for clearing heat and removing toxin, invigorating blood and resolving stasis, boiled with water for fumigation and washing. Options include nitre-alum lotion, Cong Nitre Decoction, and Two Flowers One Yellow Decoction.

2. Apply external agents for drawing out toxin, eliminating decay, and promoting tissue regeneration, such as Five Flavors Toxin-Removing Plaster.

3. When decay is eliminated and the wound surface becomes red and lively, use agents for promoting tissue regeneration and astringing, such as Skin Adhesion Powder.

4. During the acute inflammatory phase, local application of 50% magnesium sulfate solution for cold compress can be used. For recurrent and refractory cases, superficial X-ray irradiation therapy may be considered.

(3) Surgical treatment: Depending on the condition, surgery can be performed in the initial stage [first stage] or in stages.

1. For small lesions, open the base of the lesion for dressing changes.

2. For extensive lesions reaching normal fascia, perform wide excision of the infected area, with the wound healing by secondary intention [second stage] or skin grafting.

3. For larger lesions, extensive excision plus diversion colostomy may be performed. The colostomy is to avoid wound contamination and is not routine; it is generally not adopted lightly.