Background: The etiology of hidradenitis suppurativa (HS) involves genetic and environmental factors. Well-established associated systemic factors are obesity, smoking, inflammation, and bacteria. Whether localized environmental factors such as friction and pressure may also play a causative role is still unclear. Objective: To describe the possible Koebner phenomenon (KP) in HS. Methods: The case notes on 14 patients with typical HS and additional HS lesions in previously uninvolved skin areas exposed to mechanical stress, e.g., on the abdomen at the level of the waistband, were reviewed with regard to the clinical characteristics of the cohort. Results: All 14 patients (7 females) were obese with a mean BMI of 35.8 (range 30.1-45.0). All patients developed additional ectopic HS lesions at the sites of friction on the convex abdomen. The ectopic lesions were clinically and histopathologically similar to HS. Conclusion: Mechanical stress factors or trauma play a role in obese patients with HS. It is suggested that these new induced lesions fit the concept of the KP. This phenomenon seems to occur in the so-called frictional furunculoid type of HS and may explain the unique distribution at certain localizations on the body of this follicular cutaneous eruption. Removal in an early stage of HS of external stress factors that can lead to the KP should be part of the treatment, especially in obese patients.

Keywords:
Hidradenitis suppurativa, Koebner phenomenon, Mechanical stress, Obesity, Frictional furunculoid type, Distribution of hidradenitis lesions
1.
Jemec GB: Clinical practice. Hidradenitis suppurativa. N Engl J Med 2012;366:158-164.
2.
Revuz J: Hidradenitis suppurativa. J Eur Acad Dermatol Venereol 2009;23:985-998.
3.
Zouboulis CC, Desai N, Emtestam L, et al: European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa. J Eur Acad Dermatol Venereol 2015;29:619-644.
4.
Lipsker D, Severac F, Freysz M, et al: The ABC of hidradenitis suppurativa: a validated glossary on how to name lesions. Dermatology 2016;232:137-142.
5.
Zouboulis CC, Del Marmol V, Mrowietz U, et al: Hidradenitis suppurativa/acne inversa: criteria for diagnosis, severity, assessment, classification and disease evaluation. Dermatology 2015;231:184-190.
6.
Canoui-Poitrine F, Revuz JE, Wolkenstein P, et al: Clinical characteristics of a series of 302 French patients with hidradenitis suppurativa with an analysis of factors associated with disease severity. J Am Acad Dermatol 2009;61:51-57.
7.
Van der Zee HH, Laman JD, Boer J, Prens EP: Hidradenitis suppurativa: viewpoint on clinical phenotyping, pathogenesis and novel treatments. Exp Dermatol 2012;21:735-739.
8.
Boer J, Nazary M, Riis Mikkelsen P: The role of mechanical stress in hidradenitis suppurativa. Dermatol Clinics 2016;34:37-43.
9.
Köbner H: Zur Aetiologie der Psoriasis. Vierteljahresschr Dermatol Syphil 1877;8:559.
10.
Boyd AS, Nelder KH: The isomorphic response of Koebner. Int J Dermatol 1990;29:401-410.
11.
Miller RW: The Koebner phenomenon. Int J Dermatol 1982;21:192-197.
12.
Weiss G, Shemer A, Trau H: The Koebner phenomenon: review of the literature. J Eur Acad Dermatol Venereol 2002;16:241-248.
13.
Schrader AMR, Deckers IE, Van der Zee HH, et al: Hidradenitis suppurativa: a retrospective study of 846 Dutch patients to identify factors associated with disease severity. J Am Acad Dermatol 2014;71:460-467.
14.
Boer J: Resolution of hidradenitis suppurativa after weight loss by dietary measures, especially on frictional locations. J Eur Acad Dermatol Venereol 2016;30:895-896.
15.
Boer J, Mihajlovic D: Boils at frictional locations in a patient with hidradenitis suppurativa. Acta Dermatovenereol Croat 2016;24:303-304.
16.
Maher M, Larsen L: A case of radiation-induced localized exacerbation of hidradenitis suppurativa. J Am Acad Dermatol Case Reports 2016;2:44-46.
17.
Kurzen H, Kurokawa I, Jemec GBE, et al: What causes hidradenitis suppurativa? Exp Dermatol 2008;17:455-472.
18.
Alikhan A, Lynch PJ, Eisen DB: Hidradenitis suppurativa: a comprehensive review. J Am Acad Dermatol 2009;60:539-561.
19.
Kromann CB, Ibler KS, Kristianssen VB, et al: The influence of body weight on the prevalence and severity of hidradenitis suppurativa. Acta Derm Venereol 2014;94:533-537.
20.
Boer J, Weltevreden EF: Hidradenitis suppurativa or acne inversa. A clinicopathological study of early lesions. Br J Dermatol 1996;135:721-725.
21.
Von Laffert M, Helmbold P, Wohlrab J, et al: Hidradenitis (acne inversa): early inflammatory events at terminal follicles and at interfollicular epidermis. Exp Dermatol 2006;15:478-482.
22.
Von Laffert M, Stadie V, Wohlrab J, Marsch WC: Hidradenitis suppurativa/acne inversa: bilocated epithelial hyperplasia with very different sequelae. Br J Dermatol 2011;164:367-371.
23.
Janse IC, Blok JL, Diercks GFH, et al: Hidradenitis suppurativa: a disease of infundibular epidermis, rather than pilosebaceous units? Br J Dermatol DOI: 10.1111/bjd.14992.
24.
Chen W, Plewig G: Should hidradenitis suppurativa/acne inversa best be renamed as “dissecting terminal hair follicles”? Exp Dermatol DOI: 1.1111/exd.13211.
25.
Ackerman AB, Böer A, Bennin B, Gottleib GJ: Histologic Diagnosis of Inflammatory Skin Diseases, ed 3. Chatham, Ardor Scribendi, 2005.
26.
Plewig G: Follicular keratinisation. J Invest Dermatol 1974;62:308-315.
27.
Boer J, Jemec GBE: Mechanical stress and the development of pseudo-comedones and tunnels in hidradenitis suppurativa/acne inversa. Exp Dermatol 2016;25:396-397.
28.
Van Geel N, Speeckaert R, Taieb A, et al: Koebner's phenomenon in vitiligo: European position paper. Pigment Cell Melanoma Res 2011;24:564-573.
29.
Prens EP, Deckers I: Pathophysiology of hidradenitis suppurativa: an update. J Am Acad Dermatol 2015;73:S8-S11.
30.
Riis PT, Søeby K, Saunte DM, Jemec GBE: Patents with hidradenitis suppurativa carry a higher systemic inflammatory load than other dermatological patients. Arch Dermatol Res 2015;307:885-889.
31.
Miller IM, Ring HC, Prens EP, et al: Leucocyte profile in peripheral blood and neutrophil-lymphocyte ratio in hidradenitis suppurativa. A comparative cross-sectional study of 462 cases. Dermatology 2016;232:511-519.
32.
Miller IM, Elervik C, Vinding GR, et al: Association of metabolic syndrome and hidradenitis suppurativa. Arch Dermatol 2014;150:1273-1280.
33.
Canoui-Poitrine F, Le Thuaut A, Revuz J, et al: Identification of three hidradenitis suppurativa phenotypes: latent class analysis of a cross-sectional study. J Invest Dermatol 2013;133:1506-1511.
34.
Van der Zee HH, Jemec GBE: New insights into the diagnosis of hidradenitis suppurativa: clinical presentations and phenotypes. J Am Acad Dermatol 2015;73:S23-S26.
35.
Horváth B, Janse IC, Blok JL, et al: Hurley staging refined: a proposal by the Dutch hidradenitis suppurativa expert group. Acta Derm Venereol 2017;97:412-413.
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2017
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