A 40-Year-Old Man With Painful, Rupturing Lesions

Elizabeth K. Satter, MD, MPH


July 27, 2021

The differential diagnosis of indurated suppurative genital lesions include Bartholin gland abscess, cutaneous Crohn disease, and pilonidal cysts. The differential also includes lymphogranuloma venereum, granuloma inguinale, and scrofuloderma, as well as other infectious or neoplastic processes of the lymph nodes; however, these latter conditions are uncommon, especially in the United States.[2,3] After performing a comprehensive review, Alikhan and colleagues[7] concluded that a diagnosis of hidradenitis suppurativa is most likely if a patient has multiple recurrent lesions, particularly if bilateral, and located along the milk line.

The severity of hidradenitis suppurativa can be classified using various scoring systems. The most established and simplest system was initially described by Hurley[8] in 1989. Most patients have disease that is classified as Hurley stage I, which is characterized by single or multiple isolated abscesses without sinus tracts or scarring. Stage II disease manifests as recurrent abscesses, with single or multiple widely separated lesions that have limited sinus tract formation. Hurley stage III is the most severe, yet least common, presentation. Patients present with multiple abscesses and interconnected sinus tracts that are located across a broad area associated with extensive scarring.

Although the Hurley staging system is easy to use, it does not address response to treatment or disease progression; therefore, the Sartorius system was designed to provide a numerical score based on physical findings.[9] The score is based on the number of anatomical regions involved (3 points per region); number of lesions (2 points for each nodule, 4 points for each fistula, and 1 point for each scar); and longest distance between 2 lesions (2-4 points), with 6 additional points given if the lesions are not clearly separated by normal skin.[9]

Some evaluators suggest using a modified Sartorius system, which additionally includes the presence of pain, discharge, or odor. However, given the complexities of the Sartorius system, it may better suited to quantify disease in a research setting.

Chiricozzi and colleagues[10] proposed the Acne Inversa Severity Index (AISI), which was designed to combine the physician's clinical evaluation (type of lesions and the affected body sites) with the patient's quality-of-life ratings (pain, discomfort, and disability due to hidradenitis suppurativa). The authors claim that AISI is a simple, rapid, yet accurate method that better quantitates the severity of the disease in both clinical and research settings.[10]


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