Snapshot A 25-year-old woman with bipolar disorder managed by lithium presents to her dermatologist for a new onset painful rash in her inguinal area. She reports multiple lesions that seem like acne but are much larger than any acne she’s ever had. On physical exam, she has multiple deep-seated, tender, and erythematous nodules and abscesses that were openly draining purulent fluid. She is immediately given a warm compress and oral antibiotics. She is counseled about this life-long disease and is advised to stop taking lithium and find an alternative medication. Introduction Clinical definition chronic disease of occluded aprocrine glands and hair follicles characterized by painful cutaneous draining lesions, abscesses, and pilonidal sinuses this disorder does not respond well to antibiotics Epidemiology incidence 1-4% worldwide demographics 3:1 female to male ratio onset in 11-50 years of age rarely persists after menopause risk factors positive family history smoking obesity mechanical friction (wearing tight clothes) medications login to view 3 more bullets Etiology plugged apocrine gland or hair follicle Pathogenesis exact mechanism is unknown but theories include hormonal overstimulation of ductal keratinocyte production login to view 2 more bullets drug-induced disease login to view 2 more bullets Prognosis chronic disease with recurrence prognostic variable negative login to view 2 more bullets Presentation Symptoms painful lesions that drain recurrent lesions Physical exam tender nodules, pustules, or abscesses with purulent or serous drainage may coalesce into multiple draining sinuses forming a honeycombed pattern may have scars from prior lesions location most commonly occurs in axillary, inguinal, and anogenital regions Studies Labs bacterial culture to look for superinfection Diagnostic criteria 1 or more painful deep-seated nodules, abscesses, or draining sinuses poor response to antibiotics chronic and recurrent disease Differential Folliculitis Vasculitis Acne vulgaris Treatment Conservative weight loss and smoking cessation indication login to view 1 more bullet warm compresses indication login to view 1 more bullet Medical topical antibiotics indication login to view 1 more bullet drugs login to view 1 more bullet oral antibiotics indications login to view 2 more bullets drugs login to view 4 more bullets immunosuppressants indications login to view 1 more bullet drugs login to view 4 more bullets Complications Scarring and fibrosis incidence treatment Poor quality of life and psychologic burden Secondary superinfection