Introduction: Hidradenitis suppurativa (HS) is a chronic, disfiguring, and debilitating inflammatory skin condition accompanied by pain, malodorous discharge, scarring, and a scarce quality of life. Skin folds are the most frequently affected areas, while the face is rarely involved. Case Presentation: We herein report a case of a man in his 40s affected by a severe form of HS for 15 years. Physical examination showed massive, bridged scarring located on the cheeks, temporal area, chin, nuchae, and scalp. Discussion: Massive face scarring due to HS is an infrequent event and represents a further burden for patients affected by HS and a therapeutic challenge for clinicians due to the lack of codified guidelines. Novel therapies with lasers and combination therapies are emerging and may be beneficial for hypertrophic scarring in HS.

Established Facts

  • Hidradenitis suppurativa (HS) can cause dismorfing scarring with further impairment on quality of life of affected patients.

  • Face scarring due to HS is an atypical but not uncommon sequelae.

Novel Insights

  • It is important to differentiate hidradenitis suppurativa (HS) scarring from acne scarring for proper diagnosis and management of atypical HS presentations.

  • New therapies for HS scarring are emerging, including novel combinations with intralesional steroids and fractional CO2 laser.

Hidradenitis suppurativa (HS) is a chronic, disfiguring, and debilitating inflammatory skin condition causing a significant reduction in quality of life (QoL) of affected patients due to both physical and psychological burden [1]. HS usually affects young patients and tends to involve axillae, skin folds, and groins, while the face is an uncommon localization [2]. HS lesions are associated with lympho-histiocytic inflammation and granulomatous reactions; such lesions become chronic with purulent drainage, formation of sinus tracts, and scarring [3].

We herein report a case of a man in his 40s affected by a severe form of HS for 15 years. Physical examination showed massive, bridged scarring located on the cheeks, temporal area, chin, nuchae, and scalp (shown in Fig. 1); in addition, retracting scars with functional impairment localized to axillary hollows, depressed scars on chest, inflammatory nodules of inguinal region and buttocks and subcutaneous nodules localized on the chest were observed. Disease severity was classified as Hurley stage 3 and a significant impact on the QoL was also recorded (Dermatology Quality of Life = 27). At an initial stage, when the patient was 25 years old, he was diagnosed with conglobate acne and treated with isotretinoin for over 1 year with no clinical benefits. At that time, the patient began to develop hypertrophic scars on his face that were diagnosed as acne scars. About 4 years later, with the appearance of more specific lesions in body folds, a diagnosis of HS was made, and the patient was treated over time with oral and injectable antibiotics (rifampicin, clindamycin, ceftriaxone, and amoxicillin) with no clinical benefits. In 2016, therapy with adalimumab 40 mg/week was initiated and discontinued after 16 months due to loss of efficacy. Since then, the patient has exclusively managed disease-related symptoms with non-steroidal anti-inflammatory drugs.

Fig. 1.

Massive, bridged scarring on the cheeks and temporal area.

Fig. 1.

Massive, bridged scarring on the cheeks and temporal area.

Close modal

Face is considered an atypical localization for HS lesions, although atypical localization is not rare and is more frequently observed in men [2]. Face lesions in HS may resemble nodular acne lesions and can be easily confused, in fact they share common features in face localization such as nodules, burrowing abscesses, ulcerations, and polyporous and open comedones; such lesions tend to be more numerous in acne than in HS [4]. Face scarring due to HS produces bridged scarring that is highly specific for HS, and it is easy to differentiate from keloidal/hypertrophic scars caused by severe forms of acne [5]. The lack of efficacy of isotretinoin therapy, typically ineffective in patients suffering from HS and especially in severe forms, represents further proof of HSs causative role in scarring [6]. Due to the chronic relapsing inflammatory course of HS, there is a significant impairment of patients’ QoL, greater than any other dermatologic condition [7]. Localization on the face has an enormous impact on HS patients’ social life and emotional aspect. Nevertheless, the impact of HS is such as to determine consequences even in the cohabitants of affected patients [8]. Massive face scarring due to HS is an infrequent event and represents a therapeutic challenge. As in the case we presented, it is fundamental to differentiate between HS scarring and acne scarring for proper diagnosis and management of HS patients who suffer a significant impairment of QoL. There are currently no well-coded treatments for hypertrophic scars due to the lack of both high-quality studies and standardized guidelines, and frequently such treatments are not capable of obtaining satisfactory results. Instead of intralesional steroid (ILS) injections, which represents the most practiced therapy for hypertrophic scars, several different laser types, including pulsed dye lasers, ablative, and non-ablative fractional lasers, have been used to treat hypertrophic scarring due to HS and other scarring conditions, showing a benefit on scarring appearance, with consequent improvement on patient’s QoL [9]. Recently, novel combinations of therapies such as combination therapy with fractional CO2 laser and ILS demonstrated better outcomes than FCL and ILS alone [10]. According to the fact that the use of lasers in scar treatment is more and more widespread and accessible and that massive scarring which may occur in HS leads to a further impairment on QoL in HS patients, high-quality studies on laser therapies and combination therapies are an urgent need for evidence-based guidelines in order to grant higher standards of care for HS patients.

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Ethical approval was not required for this study in accordance with national guidelines. Each author listed gave his consent for publication.

None of the contributing authors has any conflict of interest, including specific financial interests or relationships and affiliations relevant to the subject matter in the manuscript.

None of the contributing authors has received any funding.

Each author listed contributed to paper design, drafting, and final revision of the work. There are no other contributors than the listed authors.

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

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