A life-threatening complication of perianal hidradenitis suppurativa

Abstract

A 50-year-old male presented with painful perianal nodules and abscesses, which had been persistent for several months. The patient reported that the lesions were initially small but progressively enlarged, causing significant discomfort and impacting his daily activities. The patient had previously undergone multiple courses of antibiotics with limited success. On physical examination, the perianal region exhibited multiple inflamed nodules, sinus tracts, and scarring (Fig. 1a). The condition was diagnosed as perianal hidradenitis suppurativa (HS). A systematic biopsy was performed to rule out malignant transformation. Histopathological examination of the biopsy revealed the presence of squamous cell carcinoma (SCC) within the chronic HS lesions (Fig. 2). The SCC was staged, and imaging studies, including included a CT scan of the abdomen and pelvis, showed no evidence of distant metastasis. The decision was to adopt a treatment plan that included wide local excision of the affected perianal tissue. The surgical procedure was conducted under general anaesthesia, during which extensive resection of the involved tissues was performed to ensure clear margins. The patient underwent wide local excision of the affected perianal tissue (Fig. 1b). Postoperatively, adjuvant radiotherapy was administered to reduce the risk of local recurrence. Remarkably, after 4 years of rigorous follow-up, the patient remains free of disease recurrence and his perianal region has shown significant improvement (Fig. 1c).

HS is a chronic inflammatory skin condition that presents significant challenges in both diagnosis and management.¹ It can lead to severe complications, including SCC.² The incidence of SCC in patients with HS is reported to be between 1% and 3.2%, with a notable male predominance among affected individuals, particularly those with perianal lesions.³ The chronic inflammation associated with HS likely contributes to epidermal hyperproliferation and subsequent mutations, facilitating malignant transformation.¹ The presence of sinus tracts in HS can further complicate the clinical picture by allowing local spread of malignant cells, which may be difficult to detect during routine examinations. This emphasizes the need for comprehensive screening protocols for patients diagnosed with HS, particularly those exhibiting high-risk features such as long-standing disease and male sex. The diagnosis of SCC in patients with HS can be particularly challenging due to the overlapping symptoms of chronic inflammation and abscess formation. Delayed diagnosis has been cited as a contributing factor to poor prognoses in these cases; for instance, a review revealed that 57% of patients with SCC arising from HS died within 2 years due to late-stage detection.⁴ Surgical intervention remains the cornerstone of treatment for malignant transformations within HS-affected areas. However, there are concerns regarding the role of anti-TNF-α therapies in promoting malignancy in HS patients.⁵ While these therapies are effective for managing HS symptoms, their potential association with increased cancer risk necessitates careful consideration and further research. Long-term follow-up is critical not only for detecting potential recurrences but also for assessing the overall health outcomes in patients who have undergone treatment for SCC secondary to HS. Vigilant monitoring and appropriate treatment strategies are crucial in managing perianal HS complicated by SCC to improve outcomes and reduce mortality rates.⁶

Written informed consent was obtained from the patient for the publication of this case report and the accompanying images.

Ayoub Zoghlami: Supervision. Houssem Messaoudi: Conceptualization; data curation; writing – review and editing. Imen Ben Ismail: Conceptualization; data curation; investigation; writing – original draft. Imen Helal: Conceptualization; data curation; formal analysis. Saber Rebii: Conceptualization; data curation. Marwen Sghaier: Conceptualization; data curation; writing – review and editing.