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Red Armpit

Discussion in 'Spot Diagnosis' started by neo_star, Feb 14, 2013.

  1. neo_star

    neo_star Moderator

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    armpit.jpg

    Hint - This condition is considered a 'dermatoses of puberty and adolescence'.
     

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  2. khine

    khine New Member

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    may be due to use of deodorant allergy
     

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  3. neo_star

    neo_star Moderator

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    i will take that as a correct answer, although the ans in this case is different; but deodorant allergy can also look like this. I will post the ans tomorrow.

    Hint: the condition has to do with the apocrine glands found in this area
     

  4. kittychan

    kittychan Well-Known Member

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    Seborrheic Dermatitis ?
     

  5. neo_star

    neo_star Moderator

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    nope
     

  6. neo_star

    neo_star Moderator

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    Answer: Hidradenitis Suppurativa

    [​IMG]



    Discussion

    This is a slightly confusing condition and i will attampt to clear some of it, by putting it as simply as possible.

    Why the confusion ?
    becuase some guys challenge the role of appocine glands being central to the pathology.

    So, i will keep the facts and allow u guys to decide.....

    1) This condition is never seen before puberty and coincides with the onset of puberty, when apocrine glands become more resposive.
    2) This condition is seen in areas of the body where apocine glands are maximally concenntrated i.e axilla. groin and gluteal cleft.
    3) It is seen more commonly in races with a higer number of appocrine glands in the axilla.
    4) It has a prediliction 4 people who r highly stressed and stress triggers the activity of the appocrine sweat glands ( possibly secondary to the hormone upheavel that results from stress ).


    What's unique about these appocrine sweat glands / how r they diff from eccrine sweat glands ?

    ans
    - they open into the hair follicles, unlike the eccrine sweat glands which open directly onto the surface of the skin.

    apocrine-sweat-glands-2.jpg

    Second difference is in the content
    - eccrine sweat glands secrete salt and water
    - appocrine glands on the other hand secreting fatty brew in addition to salt and water. It shouldn't be a surprise as the mechanism of secretion is by pinching off the apical cell membrane.


    Now a blow by blow account of the pathophysiology - it begins by plugging of the apocrine gland ducts with keratinous debris. The apocrine glands continue to secrete their stuff & the trapped bacteria, particularly - Staph aureus, Streptococcus milleri, E coli & possibly anaerobic Streptococci - feast on the high calorie meal on offer ( apocrine secretions are high in fat ), make merry and multiply. Cops arrive on the scene and seeing the unruly situation - open fire and may even call the army for back up...this sets the stage for inflammation, abscess ( due to heavy casualities on both sides ), sinus tract formation and destructive scarring.


    Treatment ( from Nelson's Pediatrics 19th ed, Chp 651)

    Patients should be counseled to avoid tight-fitting clothes, because occlusion may exacerbate the condition. Treatment with topical antibiotic agents such as chlorhexidine, erythromycin, or clindamycin or with topical retinoids may be effective in early, indolent disease. Systemic antibiotics, chosen on the basis of bacterial culture (usually staphylococcal and streptococcal pathogens) and sensitivity tests, should be administered in the acute phase. Empirical therapy may be initiated with tetracycline, doxycycline, or minocycline if the patient is 8 yr or older; clindamycin and cephalosporins also are effective. Some patients require long-term treatment with tetracycline or erythromycin. Intralesional triamcinolone acetonide (5-10 mg/mL) is often helpful in early disease. The addition of prednisone, 40-60 mg/day for 7-10 days, tapering gradually as inflammation subsides, to the regimen of patients who respond poorly to antibiotics may decrease fibrosis and scarring. Oral contraceptive agents, which contain a high estrogen-to-progesterone ratio and low androgenicity of the progesterone, or oral retinoids may be helpful in some patients. Warm compresses encourage spontaneous rupture of abscesses; those that are "pointing" should be incised and drained. Ultimately, surgical measures may be required for control or cure.



    Differential

    carbuncle and furuncle ( common boil )

    furuncle.JPG - very difficult to differentiate based on morphology as they can look exactly the same. The only clue pointing to hidradenitis suppurativa, is if the condition is localisd to the groin and axilla inspite of being recurrent and chronic. If it's furuncle then u can have it in other places as well ex. back of the neck and in children it could be becos of isolated immunoglobulin deficiencies and penicillin prophylaxis may need 2 b considered.

    for the image in this challenge - erythrasma and inverse psoriasis could be strong differentials but boggy swelling and frequent discharges are uncommon to both these conditions and strongly suggests 'Hidradenitis Suppurativa'.

    other conditions that may mimic Hidradenitis suppurativa

    - infected epidermal cysts
    - scrofuloderma
    - actinomycosis
    - cat scratch disease

    in the groin, also think of

    - Granuloma inguinale
    - Lymphogranuloma venerum


    Xtra Edge

    Follicular occlusion syndrome / triad

    The follicular occlusion syndrome refers to a group of diseases in which hair follicles become blocked with keratin (scale) and then rupture, resulting in inflammatory skin disease. These conditions commonly coexist. They may be severe and difficult to treat.

    Three of these diseases are together known as the follicular occlusion triad.

    Hidradenitis suppurativa (acne inversa)
    Acne conglobata (severe nodulocystic acne)
    Dissecting cellulitis (perifolliculitis capitis abscedens et suffodiens)

    [​IMG]

    A fourth condition, pilonidal sinus or pilonidal disease, makes up the follicular occlusion tetrad.
     

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