Photo Quiz

Inflamed, Purulent Axillary Nodules


Am Fam Physician. 2020 Jul 15;102(2):111-112.

A 21-year-old man presented with several years of recurrent painful cysts and scarring, accompanied by severe pruritus and malodorous purulent discharge in several areas, including the axillae, buttocks, and gluteal cleft. The symptoms caused physical discomfort and negatively affected the patient's quality of life.

On physical examination, the patient had multiple nodules, abscesses, interconnected tunnels, and scarring in both axillae (Figure 1). Draining tunnels and plaques were also present on his buttocks and gluteal cleft.




Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

A. Carbuncles.

B. Epidermoid cysts.

C. Hidradenitis suppurativa.

D. Pilonidal disease.


The answer is C: hidradenitis suppurativa. The diagnosis of hidradenitis suppurativa is clinical with the presence of characteristic morphologies that affect typical areas of the skin and recur at least twice within six months.1 Hidradenitis suppurativa is a chronic, relapsing inflammatory skin disease that affects areas with apocrine glands, such as the axillae, submammary region, and groin.1,2 It presents as painful nodules with malodorous discharge that progress to abscesses, tunnels (sinus tracts), and scarring.1

The Hurley staging system is used to assess the severity of hidradenitis suppurativa.3

  • Stage I (mild): nodules or abscesses but no tracts or scarring

  • Stage II (moderate): recurrent abscesses with sinus tracts and scarring

Address correspondence to Afsaneh Alavi, MD, MSc, FRCPC, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Lee EY, Alhusayen R, Lansang P, et al. What is hidradenitis suppurativa? Can Fam Physician. 2017;63(2):114–120....

2. Dufour DN, Emtestam L, Jemec GB. Hidradenitis suppurativa. Postgrad Med J. 2014;90(1062):216–221.

3. Napolitano M, Megna M, Timoshchuk EA, et al. Hidradenitis suppurativa. Clin Cosmet Investig Dermatol. 2017;10:105–115.

4. Margesson LJ, Danby FW. Hidradenitis suppurativa. Best Pract Res Clin Obstet Gynaecol. 2014;28(7):1013–1027.

5. Lee DE, Clark AK, Shi VY. Hidradenitis suppurativa: disease burden and etiology in skin of color. Dermatology. 2017;233(6):456–461.

6. Jemec GB. Clinical practice. Hidradenitis suppurativa. N Engl J Med. 2012;366(2):158–164.

7. Saunte DML, Jemec GBE. Hidradenitis suppurativa: advances in diagnosis and treatment. JAMA. 2017;318(20):2019–2032.

8. Zuber TJ. Minimal excision technique for epidermoid (sebaceous) cysts. Am Fam Physician. 2002;165(7):1409–1412. Accessed May 13, 2020.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

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