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Acne inversa of the scrotum and penis - aggressive urological treatment.
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PMID:  24578957     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
Acne inversa is a rare chronic and debilitating inflammatory skin disease. The authors report a case of a 45-year old male who presented with acne inversa in the inguinal, perineal, and scrotal areas. After unsatisfactory pharmacological treatment a wide surgical excision of the affected skin was performed in stages. On follow-up the patient presented with a very good cosmetic and functional result. A review of the most recent literature is also presented.
Authors:
Artur Gibas; Marcin Matuszewski; Igor Michajłowski; Kazimierz Krajka
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Publication Detail:
Type:  Journal Article     Date:  2012-09-04
Journal Detail:
Title:  Central European journal of urology     Volume:  65     ISSN:  2080-4806     ISO Abbreviation:  Cent European J Urol     Publication Date:  2012  
Date Detail:
Created Date:  2014-02-28     Completed Date:  2014-02-28     Revised Date:  2014-03-03    
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Nlm Unique ID:  101587101     Medline TA:  Cent European J Urol     Country:  Poland    
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Languages:  eng     Pagination:  167-9     Citation Subset:  -    
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Journal Information
Journal ID (nlm-ta): Cent European J Urol
Journal ID (iso-abbrev): Cent European J Urol
Journal ID (publisher-id): CEJU
ISSN: 2080-4806
ISSN: 2080-4873
Publisher: Polish Urological Association
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Received Day: 11 Month: 2 Year: 2012
Revision Received Day: 22 Month: 3 Year: 2012
Accepted Day: 27 Month: 3 Year: 2012
Electronic publication date: Day: 04 Month: 9 Year: 2012
Print publication date: Year: 2012
Volume: 65 Issue: 3
First Page: 167 Last Page: 169
PubMed Id: 24578957
ID: 3921795
Publisher Id: 00192
DOI: 10.5173/ceju.2012.03.art15

Acne inversa of the scrotum and penis – aggressive urological treatment
Artur Gibas1
Marcin Matuszewski1
Igor Michajłowski2
Kazimierz Krajka1
1Department of Urology, Medical University in Gdańsk, Gdańsk, Poland
2Department of Dermatology and Venerology, Medical University of Gdańsk, Gdańsk, Poland
Correspondence: Correspondence Artur Gibas, Department of Urology, 17, Smoluchowskiego Street, 80-214 Gdańsk. phone: +48 58 349 31 72. delins@gumed.edu.pl

INTRODUCTION

Acne inversa (formerly hidradenitis suppurativa) is a rare chronic and debilitating inflammatory skin disease. It forms inflammatory nodules, abscesses, fistulas, and scars in the apocrine-gland-bearing regions [1, 2]. The disease usually occurs after puberty and starts in the areas, where there is skin-to-skin contact, such as the armpits, the groins, sites under the breasts, or around the anus and genital organs. The latest concept of pathogenesis emphasizes that intrafollicular hyperkeratinization leading to the occlusion, dilation, and subsequent rupture of the follicles is the main cause of the inflammatory process. Bacterial infections seem to be a secondary factor. The hallmark of acne inversa is the formation of purulent fistulas and scarring [25]. Smoking and obesity are both known as risk factors and are associated with a more severe course of the disease [6, 7]. First-line treatment consists of topical therapy with antibiotic and comedolytic compounds. In more advanced cases systemic antibiotics, anti-inflammatory agents, and retinoids (oral/topical) are recommended. In case of conservative management failure, surgical treatment of the involved areas should be considered [8].

The authors report a case of a 45-year old male who presented with acne inversa in the inguinal, perineal, and scrotal areas. After unsatisfactory pharmacological treatment, a wide surgical excision of the affected skin was performed with good cosmetic and functional results. A review of the most recent literature is also presented.


MATERIAL AND METHOD

A male, 45 years of age, was admitted to the department of urology with the diagnosis of acne inversa located in genital organs and armpits. The first symptoms had occurred 10 years before and, despite repeated pharmacological treatments with antibiotics and retinoids, the disease gradually progressed and significantly limited the patient's sexual life. On admission the lesions were estimated at the third degree according to the Hurley scale (diffuse or broad involvement across a regional area with multiple interconnected sinus tracts and abscesses) [9]. The diagnosis was confirmed by a biopsy of the full-thickness skin and subcutaneous tissue from the scrotum.

Because of the unsatisfactory result of the previous treatment and advanced stage of penile and scrotal lesions, he was qualified for surgical treatment. The surgery was performed in stages. Procedures were done in the lithotomy position under spinal anesthesia. The scrotal operation consisted of two stage excision of diseased skin and subcutaneous tissue of the entire scrotum with a margin of 1 cm and with subsequent covering of the testes using transfer of the lipocutaneous flap to close the defects in scrotum (Fig. 1). The penile surgery began with almost total excision of the skin of the penis. Then a meshed split-thickness skin graft from the thigh was used to cover the defect (Fig. 2).

The outcome of the treatment was clinically evaluated by three independent observers within 2-years of follow-up. Attention was paid to the cosmetic result, pain, and restoration of sexual activity as well as to the extent of the remaining acne inversa lesions that were compared using the images obtained before and after surgery. Patient's preoperative and postoperative quality of life was also estimated by using Visual Analog Scale (VAS).


RESULTS

The time of each of the two first scrotal operations was 80 minutes and the third penile surgery lasted 130 minutes. The patient received ceftriaxone and metronidazole in doses of 2x1000 mg and 3x500 mg respectively for seven days post-operatively. There were no early or late surgical complications and the patient showed good tolerance to the treatment.

The inflammatory process in the genital organs has not recurred (Fig. 3). On follow-up the patient presented with a very good cosmetic and functional result that made it possible to resume a normal sexual lifestyle. His subjective score of quality of life increased nearly four times from 2.1 to 8.3 in VAS. Unfortunately, the patient still has some lesions in the armpits requiring periodic antibiotic therapy.


DISCUSSION

The term hidradenitis suppurativa was first used in 1865 by French surgeon Verneuil who linked the skin inflammation to the disease of apocrine sweat glands [7, 10]. Recently a new term, acne inversa, has been proposed but has not yet gained widespread popularity.

It is a rare disease affecting about 1% of the population [8]. The etiology remains unclear. The name suggests that it is caused primarily by follicular occlusion with secondary inflammation of the apocrine glands. The initiating events are micro-tears in the hair follicle caused by mechanical friction in the intertriginous areas of the skin [11, 12]. These tears lead to discontinuity of the epithelial lining, inflammation subsequent to leakage of follicular content, and the formation of characteristic acne inversa lesions.

Recently much attention has also been given to the role of the sebaceous gland in the etiology of acne inversa [1320]. It may be possible that propensity to acne inversa is the consequence of the loss of one or more of several sebaceous gland functions: anti-bacterial, endocrine, or anti-inflammatory [21]. So, the infection, most often caused by the colonization of Staphylococcus aureus, may be a secondary event and therefore treatment focused on bacterial elimination alone cannot be successful. It is for this reason that new topical therapies for acne inversa have been described. These new therapies are based on the administration of an anti-TNF drug such as infliximab [22, 23, 24]. Photodynamic therapy (PDT) with 20% 5-aminolevulinic acid (ALA) may also be a safe and effective option [25]. However, these results are preliminary and require more clinical studies.

Acne inversa affects patients’ lives in many aspects. Advanced disease has a significant emotional impact on patients and leads to their isolation due to fear of stigmatization. Sexual life is often disturbed if the lesions involve the sexual organs as in the presented case [26]. Unfortunately, many studies show that patients are often treated conservatively for very long periods time, even when the treatment is evidently ineffective, and that surgical intervention is not offered to them early enough [2730]. This is likely caused by the lack of knowledge about this disease, fear of surgical treatment, and the location of the lesions that make the surgical excision difficult. [2932]. On the otherhand, we know that non-effective treatment of acne inversa can lead to severe complications such as tissue contractures, systemic infections, anemia, amyloidosis, arthropathy, or even squamous cell carcinoma [33, 34].

In most cases, surgical treatment of recurrent and progressive disease should not be limited solely to skin incision and drainage. It may provide some pain relief, but is not curative and, on the contrary, often only leads to extensive scaring caused by poor wound healing. Many authors emphasize that the complete excision of the involved skin areas together with subcutaneous tissue is the only curative treatment for acne inversa [1, 9, 35]. However, wide tissue excision poses the problem of excised skin replacement [1, 9, 35]. Thus, many different kinds of skin flap techniques have been proposed for the closure of defects in acne inversa, such as: lipocutaneous, fasciocutaneous, myocutaneous, and free flaps [27, 30, 3639].

In the presented case we chose the lipocutaneous flap to close the defects on the scrotum and a meshed split-thickness skin graft to cover the penile shaft. It must be underlined that meticulous dressing care and antibiotic therapy were crucial to achieve proper healing.

The described technique resulted in less deformation of the organs and made it possible to obtain good graft acceptance and wound healing [40, 41]. The follow-up did not reveal any new lesions in the operated areas, but the patient will be monitored further as the disease may recur [42].


CONCLUSIONS

Sometimes the only curative option for extensive acne inversa affecting the sexual organs is aggressive surgery. Delaying its implementation may lead to severe local and generalized complications. In the presented case the surgical treatment was effective and well tolerated. We recommend it for all advanced cases of acne inversa as well as those resistant to conservative treatment. However, such therapy should be performed in centers with expertise in penile surgery.


REFERENCES
1. Poli F,Jemec GB,Revuz J. Jemec GBE,Revuz J,Leyden JJClinical presentationHidradenitis SuppurativaYear: 2006HeidelbergSpringer1124
2. Yazdanyar S,Jemec GB. Hidradenitis suppurativa: a review of cause and treatmentCurr Opin Infect DisYear: 201124211812321192260
3. Yu CC,Cook MG. Hidradenitis suppurativa: a disease of follicular epithelium, rather than apocrine glandsBr J DermatolYear: 19901227637692369556
4. Jemec GB,Hansen U. Histology of hidradenitis suppurativaJ Am Acad DermatolYear: 1996349949998647993
5. Jemec GB,Thomsen BM,Hansen U. The homogeneity of hidradenitis suppurativa lesions. A histological study of intra-individual variationAPMISYear: 1997105378839201239
6. Meixner D,Schneider S,Krause M,et al. Acne inversaJ Dtsch Dermatol GesYear: 2008618919618093218
7. Jemec GB,Revuz J,Leyden J. Hidradenitis suppurativaYear: 20061st ednSpringer
8. Jemec GB. Medical treatment of hidradenitis suppurativaExpert Opin PharmacotherYear: 200451767177015264991
9. Hurley HJ. Roenigk RK,Roenigk HHAxillary hyperhidrosis, apocrine bromhidrosis, hidradenitis suppurativa, and familial benign pemphigus: surgical approacDermatologic surgery, principles and practiceYear: 1996New York, Basel, Hong KongMarcel Dekker623645
10. Verneuil AS. Etudes sur les tumor de la peauArch Gen MedYear: 185494693
11. Kurzen H,Kurokawa I,Jemec GB,et al. What causes hidradenitis suppurativa?Exp DermatolYear: 20081745545618400064
12. Dufour DN,Bryld LE,Jemec GB. Hidradenitis suppurativa complicating naevus comedonicus: the possible influence of mechanical stress on the development of hidradenitis suppurativaDermatologyYear: 201022032332520389029
13. Zhang Q,Seltmann H,Zouboulis CC,et al. Activation of platelet-activating factor receptor in SZ95 sebocytes results in inflammatory cytokine and prostaglandin E2 productionExp DermatolYear: 20061576977416984258
14. Zhang Q,Seltmann H,Zouboulis CC,et al. Involvement of PPARgamma in oxidative stress-mediated prostaglandin E(2) production in SZ95 human sebaceous gland cellsJ Invest DermatolYear: 2006126424816417216
15. Alestas T,Ganceviciene R,Fimmel S,et al. Enzymes involved in the bio-synthesis of leukotriene B4 and prostaglandin E2 are active in sebaceous glandsJ Mol MedYear: 200684758716388388
16. Thiboutot D,Jabara S,McAllister JM,et al. Human skin is a steroidogenic tissue: steroidogenic enzymes and cofactors are expressed in epidermis, normal sebocytes, and an immortalized sebocyte cell line (SEB-1)J Invest DermatolYear: 200312090591412787114
17. Wille JJ,Kydonieus A. Palmitoleic acid isomer (C16:1delta6) in human skin sebum is effective against gram-positive bacteriaSkin Pharmacol Appl Skin PhysiolYear: 20031617618712677098
18. Boehm KD,Yun JK,Strohl KP,et al. Messenger RNAs for the multifunctional cytokines interleukin-1 alpha, interleukin-1 beta and tumor necrosis factor-alpha are present in adnexal tissues and in dermis of normal human skinExp DermatolYear: 199543353418608340
19. Lee DY,Yamasaki K,Rudsil J,et al. Sebocytes express functional cathelicidin antimicrobial peptides and can act to kill propionibacterium acnesJ Invest DermatolYear: 20081281863186618200058
20. Fimmel S,Zouboulis CC. Influence of physiological androgen levels on wound healing and immune status in menAging MaleYear: 2005816617416390741
21. Kamp S,Fiehn AM,Stenderup K,et al. Hidradenitis Suppurativa - the disease of the absent sebaceous gland?Br J DermatolYear: 2011164/51017102221250966
22. Thielen AM,Barde C,Saurat JH. Long-term infliximab for severe hidradenitis suppurativaBr J DermatolYear: 20061551105110717034567
23. Haslund P,Lee RA,Jemec GB. Treatment of hidradenitis suppurativa with tumour necrosis factoralpha inhibitorsActa Derm VenereolYear: 20098959560019997689
24. Grant A,Gonzalez T,Montgomery MO,et al. Infliximab therapy for patients with moderate to severe hidradenitis suppurativa: a randomized, double-blind, placebo-controlled crossover trialJ Am Acad DermatolYear: 20106220521720115947
25. Schweiger ES,Riddle CC,Aires DJ. Treatment of hidradenitis suppurativa by photodynamic therapy with aminolevulinic Acid: preliminary resultsJ Drugs DermatolYear: 2011Day: 1 104381338621455548
26. Esmann S,Jemec GB. Psychosocial Impact of Hidradenitis Suppurativa: A QualitativeStudy Acta Derm VenereolYear: 201191328332
27. Kagan RJ,Yakuboff KP,Warner P,Warden GD. Surgical treatment of hidradenitis suppurativa: a 10-year experienceSurgeryYear: 200513873474016269303
28. Mandal A,Watson J. Experience with different treatment modules in hidradenitis suppuritiva: a study of 106 casesSurgeonYear: 20053232615789789
29. Stein A,Sebastian G. Acne inversaHautarztYear: 20035417318512691077
30. Weyandt G. Surgical management of acne inversaHautarzt6Year: 20055610331039
31. Lentner A,Rubben A,Wienert V. Klinisches Erscheinungsbild und Therapie der Pyodermia fistulans sinifica (Acne inversa)Z HautkrYear: 199267988992
32. Rompel R,Petres J. Long-term results of wide surgical excision in 106 patients with hidradenitis suppurativaDermatol SurgYear: 20002663864310886270
33. Talmant JC,Bruant-Rodier C,Nunziata AC,et al. Squamous cell carcinoma arising in Verneuil's disease: two cases and literature review (in French)Ann Chir Plast EsthetYear: 2006511828616488526
34. Short KA,Kalu G,Mortimer PS,Higgins EM. Vulval squamous cell carcinoma arising in chronic hidradenitis suppurativaClin Exp DermatolYear: 200530548148316045671
35. Alikhan A,Lynch PJ,Eisen DB. Hidradenitis suppurativa: a comprehensive reviewJ Am Acad DermatolYear: 20096053956119293006
36. Tanaka A,Hatoko M,Tada H,et al. Experience with surgical treatment of hidradenitis suppurativaAnn Plast SurgYear: 20014763664211756834
37. Geh JL,Niranjan NS. Perforator-based fasciocutaneous island flaps for the reconstruction of axillary defects following excision of hidradenitis suppurativaBr J Plast SurgYear: 20025512412811987945
38. Rehman N,Kannan RY,Hassan S,Hart NB. Thoracodorsal artery perforator (TAP) type I V-Y advancement flap in axillary hidradenitis suppurativaBr J Plast SurgYear: 20055844144415897024
39. Chuang CJ,Lee CH,Chen TM,et al. Use of a versatile transpositional flap in the surgical treatment of axillary hidradenitis suppurativaJ Formos Med Asso6cYear: 2004103644647
40. Pollock WJ,Virnelli FR,Ryan RF. Axillary hidradenitis suppurativa. A simple and effective surgical techniquePlast Reconstr SurgYear: 19724922274550068
41. Anderson DK,Perry AW. Axillary hidradenitisArch SurgYear: 197511069721115611
42. Jemec GB. The symptomatology of hidradenitis suppurativa in womenBr J DermatolYear: 19881193453503179207

Figures

[Figure ID: F0001]
Fig. 1 

Scrotal lipocutaneous flap transfer.



[Figure ID: F0002]
Fig. 2 

The partial-thickness skin graft from thigh used to cover the penile skin defect.



[Figure ID: F0003]
Fig. 3 

Result after 2 years of follow-up.



Article Categories:
  • Case Report

Keywords: acne inversa, hidradenitis suppurativa, scrotum, penis.

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