A Case Report of Adolescent Hidradenitis Suppurativa with Recurrent Inflammatory Abscesses and Disease Burden

Technical Summary: A Case Report of Adolescent Hidradenitis Suppurativa with Recurrent Inflammatory Abscesses and Disease Burden

Problem Statement
Hidradenitis suppurativa (HS), or acne inversa, is a chronic autoinflammatory cutaneous disorder characterized by recurrent painful nodules, abscesses, and sinus tracts in intertriginous areas (axillary, inguinal, perianal, and intermammary). While predominantly affecting females, the disease often presents with a severe burden, including physical pain, scarring, and significant psychosocial impact. A critical clinical challenge lies in understanding the interrelationship between HS and its frequent comorbidities, which include metabolic syndrome, Polycystic Ovary Syndrome (PCOS), acne vulgaris, and psychological distress. The pathogenesis involves follicular occlusion, autoinflammation driven by cytokines such as Interleukin-17 (IL-17) and Tumor Necrosis Factor-alpha (TNF-α), and is exacerbated by factors like obesity and smoking. Despite available treatments ranging from topical antibiotics to biologics, managing the chronic, relapsing nature of HS alongside its systemic comorbidities remains complex, particularly in adolescent populations.

Methodology
This study employs a single-case report design focusing on a 17-year-old female patient. The methodology involves a retrospective and prospective analysis of the patient's clinical history, physical examinations, and laboratory investigations over a four-year period (onset at age 13).

• Clinical Assessment: The patient was diagnosed with Hurley Stage III HS based on the presence of recurrent inflammatory abscesses and chronic relapsing disease activity.
• Diagnostic Workup: Comprehensive evaluation included dermatological examination, body weight monitoring, and laboratory testing for endocrine and metabolic markers (fasting insulin, serum prolactin, hemoglobin).
• Intervention: The treatment protocol was multimodal, consisting of:
  • Topical Therapy: Clindamycin phosphate lotion and benzoyl peroxide-based cleansing wash.
  • Systemic Therapy: Oral isotretinoin (20 mg daily) for concurrent acne vulgaris and adapalene-based topical therapy.
  • Lifestyle Management: Physician-directed weight reduction and stress control strategies.
  • Surgical History: Review of a prior para-ovarian cyst surgery (December 2022).
• Monitoring: Disease progression was tracked through the frequency of flare-ups, lesion morphology (nodules, abscesses, discharge), and resolution time (typically 3–4 days per episode).

Key Results
The patient presented with a four-year history of HS involving the axillary and groin regions, characterized by tender boils evolving into recurrent nodules and abscesses.

• Comorbidity Profile: The patient exhibited a complex cluster of conditions including borderline Polycystic Ovary Syndrome (PMOS/PCOS), acne vulgaris, hyperinsulinemia (fasting insulin 30 µIU/mL), hyperprolactinemia (50 ng/mL), and anemia (hemoglobin 9 g/dL).
• Disease Course: The clinical course demonstrated a chronic relapsing pattern. Flare-ups typically began as painful boils progressing to inflammatory nodules and abscesses (Hurley Stage II/III). While early episodes featured purulent and bloody discharge, the frequency and severity of discharge decreased over time. Lesions often healed with residual post-inflammatory scarring.
• Treatment Response: The combination of pharmacological therapy (isotretinoin, clindamycin, adapalene) and lifestyle modifications (weight loss, stress management) resulted in partial symptomatic improvement and a reduction in overall disease severity. However, intermittent flare-ups persisted, indicating the chronic nature of the condition.
• Associated Findings: The patient developed eczema in the areolar region, which resolved following the medical management of hyperprolactinemia.

Significance and Claims
The authors assert that this case is significant primarily for delineating the potential connection between the endocrine system, psychological health, and the immune system in an adolescent onset of HS.

• Pathophysiological Insight: The case highlights the interplay of hormonal and inflammatory pathways, suggesting that elevated IL-17 and TNF-α activity may drive the interrelationship between HS, PMOS, and acne vulgaris.
• Contributing Factors: The report emphasizes that obesity and hyperinsulinemia are significant contributors to HS severity, reinforcing the need for metabolic management alongside dermatological treatment.
• Holistic Management: The authors claim that maintaining mental well-being is as critical as medical intervention, noting that recurrent flare-ups and scarring severely deteriorated the patient's quality of life and self-esteem.
• Therapeutic Recommendations: The paper advocates for a comprehensive approach including topical and oral medications, an anti-inflammatory diet, and moderate to heavy exercise to reduce pain and lesion frequency. It concludes that HS is an autoinflammatory condition driven by inter-related pathways rather than an infection or a fault of the patient.

The paper does not propose new experimental therapies or future clinical trials but rather uses this specific case to underscore the necessity of addressing comorbidities and lifestyle factors in the management of adolescent HS.