From the publishers of The New England Journal of Medicine

Pores in Pores: Defective Follicles May Lead to Hidradenitis Suppurativa

Morphological defects may lead to fragility of the sebofollicular junction, allowing leakage of keratin fragments that trigger an inflammatory response. Hidradenitis suppurativa (HS) causes painful abscesses and chronic draining sinus tracts. Its purulent nature suggests an infectious etiology, but most isolated bacteria remain nonpathogenic, and systemic antibiotics fail to control the disease. What is the starting point? Is there an abnormality of follicles in apocrine glandrich areas? A follicular abnormality is suggested by follicular hyperkeratosis seen in biopsy specimens and by dilated follicular pores seen clinically. Investigators obtained specimens of HS-affected skin removed by wide excision from 20 patients. Histologic study focused on three specimens per patient of periodic acid Schiff (PAS) staining of basement membrane zones (BMZs): One from the center of a "lesion," one from the excision margin, and one from an area in between. Staining intensity was assessed using a 5-point qualitative grading system. As a control, the authors studied nine specimens of clinically normal axillary skin. The interfollicular BMZ always stained brightly and acted as a positive control for each specimen. In contrast, the BMZ of the sebofollicular junction was absent, fragmented, or wispy. When inflammation was present, inflammatory cell concentrations were greatest in areas where the BMZ PAS-positivity was wispy or absent. Cause-and-effect relationships were uncertain, but inflammation was seen around other areas of follicles with normal-staining basement membranes, suggesting the primary abnormality was related to the folliculopilosebaceous unit. The authors suggest that lack of a BMZ barrier allows trauma to push follicular materials into the dermis, which causes inflammation by activating innate and adaptive immune systems. In sinus tracts, PAS-positive material at the BMZ was uniformly dense and homogeneous, suggesting new construction by cells derived from pluripotent stem cells. Comment: I believe hidradenitis suppurativa to be a disease of abnormal follicles. Clinical findings suggest this; follicles in hidradenitis suppurativeaffected areas are frequently abnormal, with dilations and comedos, often multiorifaced. A defect of terminal differentiation of the acroinfundibulum may allow impactions within the follicle, which then penetrate into the skin through an abnormality at the basement membrane zone. I wonder why the PAS+ BMZ is abnormal, and why the abnormalities are confined to the zone where the sebaceous gland duct meets the follicle itself. Mark V. Dahl, MD

Published in Journal Watch Dermatology February 8, 2013

CITATION(S):
William Danby F et al. Preliminary findings suggest hidradenitis suppurativa may be due to defective follicular support. Br J Dermatol 2013 Jan 16; [e-pub ahead of print]. (http://dx.doi.org/10.1111/bjd.12233).