
 acne inversa ( formerly hidradenitis suppurativa ) is a rare chronic and debilitating inflammatory skin disease .
it forms inflammatory nodules , abscesses , fistulas , and scars in the apocrine - gland - bearing regions [ 1 , 2 ] .
the disease usually occurs after puberty and starts in the areas , where there is skin - to - skin contact , such as the armpits , the groins , sites under the breasts , or around the anus and genital organs .
the latest concept of pathogenesis emphasizes that intrafollicular hyperkeratinization leading to the occlusion , dilation , and subsequent rupture of the follicles is the main cause of the inflammatory process .
the hallmark of acne inversa is the formation of purulent fistulas and scarring [ 25 ] .
smoking and obesity are both known as risk factors and are associated with a more severe course of the disease [ 6 , 7 ] .
first - line treatment consists of topical therapy with antibiotic and comedolytic compounds . in more advanced cases systemic antibiotics , anti - inflammatory agents , and retinoids ( oral / topical )
are recommended . in case of conservative management failure , surgical treatment of the involved areas should be considered .
the authors report a case of a 45-year old male who presented with acne inversa in the inguinal , perineal , and scrotal areas .
after unsatisfactory pharmacological treatment , a wide surgical excision of the affected skin was performed with good cosmetic and functional results .
a male , 45 years of age , was admitted to the department of urology with the diagnosis of acne inversa located in genital organs and armpits .
the first symptoms had occurred 10 years before and , despite repeated pharmacological treatments with antibiotics and retinoids , the disease gradually progressed and significantly limited the patient 's sexual life . on admission
the lesions were estimated at the third degree according to the hurley scale ( diffuse or broad involvement across a regional area with multiple interconnected sinus tracts and abscesses ) .
the diagnosis was confirmed by a biopsy of the full - thickness skin and subcutaneous tissue from the scrotum .
because of the unsatisfactory result of the previous treatment and advanced stage of penile and scrotal lesions , he was qualified for surgical treatment .
the scrotal operation consisted of two stage excision of diseased skin and subcutaneous tissue of the entire scrotum with a margin of 1 cm and with subsequent covering of the testes using transfer of the lipocutaneous flap to close the defects in scrotum ( fig .
then a meshed split - thickness skin graft from the thigh was used to cover the defect ( fig .
the partial - thickness skin graft from thigh used to cover the penile skin defect .
the outcome of the treatment was clinically evaluated by three independent observers within 2-years of follow - up .
attention was paid to the cosmetic result , pain , and restoration of sexual activity as well as to the extent of the remaining acne inversa lesions that were compared using the images obtained before and after surgery .
patient 's preoperative and postoperative quality of life was also estimated by using visual analog scale ( vas ) .
the time of each of the two first scrotal operations was 80 minutes and the third penile surgery lasted 130 minutes .
the patient received ceftriaxone and metronidazole in doses of 2x1000 mg and 3x500 mg respectively for seven days post - operatively .
there were no early or late surgical complications and the patient showed good tolerance to the treatment .
the patient presented with a very good cosmetic and functional result that made it possible to resume a normal sexual lifestyle .
his subjective score of quality of life increased nearly four times from 2.1 to 8.3 in vas .
unfortunately , the patient still has some lesions in the armpits requiring periodic antibiotic therapy .
the term hidradenitis suppurativa was first used in 1865 by french surgeon verneuil who linked the skin inflammation to the disease of apocrine sweat glands [ 7 , 10 ] . recently
a new term , acne inversa , has been proposed but has not yet gained widespread popularity .
the name suggests that it is caused primarily by follicular occlusion with secondary inflammation of the apocrine glands .
the initiating events are micro - tears in the hair follicle caused by mechanical friction in the intertriginous areas of the skin [ 11 , 12 ] .
these tears lead to discontinuity of the epithelial lining , inflammation subsequent to leakage of follicular content , and the formation of characteristic acne inversa lesions .
recently much attention has also been given to the role of the sebaceous gland in the etiology of acne inversa 
 [ 1320 ] .
it may be possible that propensity to acne inversa is the consequence of the loss of one or more of several sebaceous gland functions : anti - bacterial , endocrine , or anti - inflammatory .
so , the infection , most often caused by the colonization of staphylococcus aureus , may be a secondary event and therefore treatment focused on bacterial elimination alone can not be successful .
it is for this reason that new topical therapies for acne inversa have been described .
these new therapies are based on the administration of an anti - tnf drug such as infliximab [ 22 , 23 , 24 ] .
photodynamic therapy ( pdt ) with 20% 5-aminolevulinic acid ( ala ) may also be a safe and effective option .
advanced disease has a significant emotional impact on patients and leads to their isolation due to fear of stigmatization .
sexual life is often disturbed if the lesions involve the sexual organs as in the presented case .
unfortunately , many studies show that patients are often treated conservatively for very long periods time , even when the treatment is evidently ineffective , and that surgical intervention is not offered to them early enough [ 2730 ] .
this is likely caused by the lack of knowledge about this disease , fear of surgical treatment , and the location of the lesions that make the surgical excision difficult .
[ 2932 ] . on the otherhand , we know that non - effective treatment of acne inversa can lead to severe complications such as tissue contractures , systemic infections , anemia , amyloidosis , arthropathy , or even squamous cell carcinoma [ 33 , 34 ] . in most cases , surgical treatment of recurrent and progressive disease should not be limited solely to skin incision and drainage .
it may provide some pain relief , but is not curative and , on the contrary , often only leads to extensive scaring caused by poor wound healing .
many authors emphasize that the complete excision of the involved skin areas together with subcutaneous tissue is the only curative treatment for acne inversa 
 [ 1 , 9 , 35 ] .
however , wide tissue excision poses the problem of excised skin replacement [ 1 , 9 , 35 ] .
thus , many different kinds of skin flap techniques have been proposed for the closure of defects in acne inversa , such as : lipocutaneous , fasciocutaneous , myocutaneous , and free flaps [ 27 , 30 , 3639 ] . in the presented case we chose the lipocutaneous flap to close the defects on the scrotum and a meshed split - thickness skin graft to cover the penile shaft .
it must be underlined that meticulous dressing care and antibiotic therapy were crucial to achieve proper healing .
the described technique resulted in less deformation of the organs and made it possible to obtain good graft acceptance and wound healing [ 40 , 41 ] .
the follow - up did not reveal any new lesions in the operated areas , but the patient will be monitored further as the disease may recur .
sometimes the only curative option for extensive acne inversa affecting the sexual organs is aggressive surgery . delaying its implementation may lead to severe local and generalized complications . in the presented case the surgical treatment was effective and well tolerated .
we recommend it for all advanced cases of acne inversa as well as those resistant to conservative treatment .
 acne inversa is a rare chronic and debilitating inflammatory skin disease.the authors report a case of a 45-year old male who presented with acne inversa in the inguinal , perineal , and scrotal areas . after unsatisfactory pharmacological treatment 
 a wide surgical excision of the affected skin was performed in stages . on follow - up 
 the patient presented with a very good cosmetic and functional result . 
 a review of the most recent literature is also presented . 
INTRODUCTION
MATERIAL AND METHOD
RESULTS
DISCUSSION
CONCLUSIONS