Considering hidradenitis suppurativa as a bacterial biofilm disease

Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the skin that results in a relapsing course of painful draining sinuses and abscesses. The disease manifests largely in the apocrine glandbearing regions of the body (axillary, inguinal and anogenital areas) and is usually treated by antibiotics and/or surgery. The exact pathogenesis of HS is still in dispute, but likely multifactorial; in some instances, a genetic component has been demonstrated. While much attention has been given to the cellular and molecular biology of the host tissues affected by HS, rather less has been given to the bacteria involved (most commonly Staphylococci or Streptococci). We note that the characteristics of HS comport exactly with the features of bacterial biofilm-based infections, and examined a case where HS of the buttocks had progressed to an advanced stage. Physical examination of the sinus tracks at surgery revealed a mucinous accumulation consistent with biofilm formation. Confocal microscopic examination using Live/Dead staining revealed clusters of bacteria attached to the sinus luminal surfaces. The paradigmatic clinical features of HS, coupled with the adherent bacterial communities we observe here, suggest that HS should be considered in the expanding spectrum of bacterial biofilm-based disorders.