Can hidradenitis suppurativa cause cysts in the breast?

Hidradenitis Suppurativa and Breast Cysts

Yes, hidradenitis suppurativa can cause cysts in the breast area, particularly in the submammary and intermammary folds where apocrine gland-bearing skin is present. 1, 2

Clinical Presentation in Breast Tissue

• Hidradenitis suppurativa (HS) commonly affects flexural areas including the submammary region and intermammary folds, where it can manifest as painful nodules, abscesses, sinus tracts, and cysts 1, 3
• When affecting the periareolar region, HS can be confused with other breast conditions, leading to diagnostic delays and inappropriate management 2
• HS breast lesions typically present with:
  • Painful inflammatory nodules and abscesses 2, 4
  • Chronic purulent or serous discharge 1
  • Persistent malodor 1, 5
  • Sinus tract and fistula formation in more advanced disease 1
  • Scarring and fibrosis with long-standing disease 1

Diagnostic Considerations

• The diagnosis of HS in the breast requires:
  • Typical lesions (painful nodules, abscesses, sinus tracts, bridged scars, or open comedones) 1
  • Location in typical sites (including submammary and intermammary regions) 1, 6
  • Chronicity and recurrence of the disease 1
• HS is primarily a clinical diagnosis and histopathological confirmation is rarely needed 1
• Common histopathological features include:
  • Follicular hyperkeratosis and hyperplasia 1
  • Follicular occlusion with spongiform infundibulofolliculitis 1
  • Formation of keratin-containing cysts lined by stratified squamous epithelium 1
  • Abscesses, sinus tracts, granulomas, fibrosis, and scarring in advanced disease 1

Disease Severity Assessment

• Severity of HS, including breast involvement, is commonly assessed using:
  • Hurley staging system (stages I-III) 1
  • Hidradenitis Suppurativa Clinical Response (HiSCR) to measure treatment efficacy 1
  • Pain assessment using visual analog scale or numeric rating scale 1
  • Quality of life measures such as Dermatology Life Quality Index (DLQI) 1

Management Approach for Breast HS

• Medical therapy options include:
  • Topical treatments: Clindamycin 1% solution/gel twice daily for 12 weeks for mild disease 1
  • Systemic antibiotics:
    • Tetracycline 500 mg twice daily for 4 months for mild-to-moderate disease 1
    • Clindamycin 300 mg twice daily with Rifampicin 600 mg once daily for 10 weeks for moderate-to-severe disease 1
  • Biologics: Adalimumab (160 mg at week 0,80 mg at week 2, then 40 mg weekly) for moderate-to-severe disease 1
• Surgical interventions may be necessary for advanced cases:
  • Deroofing technique for abscesses and sinus tracts is preferred over simple incision and drainage 1
  • Incision and drainage has high recurrence rates (approaching 100%) but may provide acute relief when other methods are not feasible 1

Associated Comorbidities and Risk Factors

• Risk factors that may exacerbate HS include:
  • Obesity (prevalence >75% in HS patients) 1
  • Smoking 1
• Important comorbidities to screen for in HS patients:
  • Depression and anxiety 1
  • Inflammatory bowel disease 1
  • Metabolic syndrome and cardiovascular disease 1
  • Spondyloarthritis 1

Clinical Pitfalls and Considerations

• HS in the breast is often misdiagnosed, leading to inappropriate management and treatment delays 2, 7
• Differential diagnosis should include other inflammatory breast conditions, breast abscesses, and malignancy 2
• HS has a significant impact on quality of life due to pain, discharge, malodor, and disfigurement 1, 5
• Women are disproportionately affected by HS (three times more common than in men) 3, 4
• Obstetrician-gynecologists and primary care physicians should be aware of HS presentation in the breast to facilitate early diagnosis and appropriate referral 4