Hidradenitis Suppurativa Involvement of the Scrotum

Definition and Clinical Presentation

Hidradenitis suppurativa (HS) is a chronic, inflammatory, recurrent, debilitating skin follicular disease that typically presents after puberty with painful deep-seated, inflamed lesions in areas with apocrine gland-bearing skin, including the scrotum in males 1
The most commonly affected areas include the axillae, inguinal region, anogenital region (including scrotum in males), perineal region, perianal region, infra- and intermammary folds, and buttocks 1
When HS affects the scrotum, it typically presents as painful nodules, abscesses, or inflammatory lesions, sinus tracts and fistulae in more advanced cases, chronic discharge, persistent malodor, and scarring and fibrosis with long-standing disease 1

The diagnosis of HS, including scrotal involvement, requires typical lesions (painful nodules, abscesses, sinus tracts, bridged scars, or open comedones) and occurrence in typical sites (including the anogenital region where the scrotum is located), as well as chronicity and recurrence of the disease 1, 2

The severity of HS, including scrotal involvement, is commonly assessed using the Hurley staging system, which includes three stages: single or multiple isolated abscess formation without scarring or sinus tracts (Stage I), recurrent abscesses with tract formation and scarring (Stage II), and diffuse or near-diffuse involvement with multiple interconnected tracts and abscesses (Stage III) 1

When evaluating scrotal lesions, it's essential to distinguish HS from other conditions, such as Fournier gangrene, folliculitis, pilonidal disease, and pyoderma gangrenosum 3, 4, 5

Medical therapy options for scrotal HS include topical antiseptics and antibiotics, systemic antibiotics (tetracyclines, clindamycin, rifampicin), and biologics (adalimumab for moderate-to-severe disease) 1, 2
Surgical interventions may be necessary for advanced or refractory cases, including incision and drainage for acute abscesses 1

Scrotal HS can significantly impact quality of life and sexual function, and is associated with various comorbidities, such as depression and anxiety, inflammatory bowel disease, spondyloarthritis, and cardiovascular risk factors 5, 6
Risk factors that may exacerbate scrotal HS include obesity and smoking 1, 7