Cutaneous squamous cell carcinoma complicating hidradenitis suppurativa: a review of the prevalence, pathogenesis, and treatment of this dreaded complication

A state-of-the-art systematic review of cancer in hidradenitis suppurativa

PURPOSE

Hidradenitis suppurativa (HS) is a chronic inflammatory disease associated with an increased risk of malignancy. The aim of this systematic review was to investigate the prevalence of different malignancies in HS.

METHODS

This review meets the PRISMA criteria. A data-driven approach was used to conduct the research, which involved a detailed keyword search. The study considered meta-analyses, experimental studies, case-control studies, cross-sectional studies, cohort studies, and recently published cases, published in English or German. Excluded were reviews, summaries, and letters to the editor, as well as studies, which are not based on the human population.

RESULTS

Out of the initial 443 publications found, 25 met the inclusion criteria for this systematic review. Patients with HS have a significantly increased risk of cancer, up to 50%. Additionally, the risk of oropharyngeal, central nervous system, colorectal, prostate, vulvar and non-melanocytic skin cancers increase with the severity of HS. The likelihood of comorbid lymphoma in patients with HS is significantly higher compared to healthy controls. In severe cases of HS, malignant degeneration of lesions in the groin, perianal, perineal, and gluteal region can occur in up to 4.6% of cases. This leads to the development of cSCC, which often have a complicated course, are more refractory to treatment and associated with a poorer outcome. The pathogenic mechanisms responsible for the malignant transformation of HS are currently unknown.

CONCLUSIONS

Patients with HS have a higher risk of cancer compared to the general population. Untreated, long-standing HS lesions can lead to complicated malignant degeneration resulting in cutaneous squamous cell carcinoma. The mechanisms underlying this malignant degeneration are not fully understood. HS patients also have an increased risk of developing other cancers, including prostate, oral, pharyngeal and colorectal cancers of the central nervous system and lymphomas.

S2k‐Leitlinie zur Therapie der Hidradenitis suppurativa/Acne inversa – Kurzfassung

Die S2k‐Leitlinie der Hidradenitis suppurativa/Acne inversa (HS/AI) soll eine akzeptierte Entscheidungshilfe für die Auswahl/Durchführung einer geeigneten/suffizienten Therapie liefern. Hidradenitis suppurativa/Acne inversa ist eine chronisch‐rezidivierende, entzündliche, potenziell mutilierende Hauterkrankung des terminalen Haartalgdrüsenapparats, mit schmerzhaften, entzündlichen Läsionen in den apokrinen drüsenreichen Körperregionen. Ihre Punktprävalenz in Deutschland ist 0,3%, sie wird mit einer Verspätung von 10,0 ± 9,6 Jahren diagnostiziert. Abnormale Differenzierung der Keratinozyten des Haartalgdrüsenapparats und eine begleitende Entzündung bilden die zentrale pathogenetische Grundlage. Primäre HS/AI‐Läsionen sind entzündliche Knoten, Abszesse und drainierende Tunnel. Rezidive in den letzten 6 Monaten mit mindestens zwei Läsionen an den Prädilektionsstellen verweisen auf eine HS/AI mit einer 97‐prozentigen Genauigkeit. HS/AI‐Patienten leiden an einer deutlichen Einschränkung der Lebensqualität. Zur korrekten Therapieentscheidung sollen Klassifikation und Aktivitätsbewertung mit einem validierten Instrument erfolgen, wie dem International Hidradenitis Suppurativa Severity Scoring System (IHS4). Hidradenitis suppurativa/Acne inversa wird nach der Ausprägung der nachweisbaren Entzündung in zwei Formen eingeteilt: aktive, entzündliche (milde, mittelschwere und schwere nach IHS4) und vorwiegend inaktive, nicht entzündliche (Hurley‐Grad‐I, ‐II und ‐III) HS/AI. Orale Tetrazykline oder eine 5‐tägige intravenöse Therapie mit Clindamycin sind mit der Effektivität von Clindamycin/Rifampicin vergleichbar. Subkutan applizierbares Adalimumab, Secukinumab und Bimekizumab sind für die Therapie der HS/AI zugelassen. Für die vorwiegend nicht entzündliche Erkrankungsform stehen verschiedene operative Verfahren zur Verfügung. Medikamentöse/chirurgische Kombinationen gelten als ganzheitliches Therapieverfahren.

Multiple verrucous squamous cell carcinomas developing on chronic hidradenitis suppurativa lesions-a rare case report from Romania

Hidradenitis suppurativa (HS) is an uncommon, recurrent, inflammatory skin illness of the apocrine glands, with a questionable etiology. The disease is associated with a multitude of comorbidities, of which the appearance of malignancy is the most important. Squamous cell carcinoma is considered the most frequent malignancy that can appear in HS. A case report of a 72 years-old male is presented, who suffered over 40 years from persistent, extensive hidradenitis suppurativa in stage Hurley III, on the buttocks and perianal region, who recently presented two verrucous semi-consistent, skin-colored tumors on the right buttock. The biopsy and histopathological exam confirmed a verrucous type of squamous cell carcinoma. There are about 100 reported clinical cases of squamous cell carcinoma complicating hidradenitis suppurativa in the literature, but only a few describe a verrucous carcinoma as a clinical form. The particularity of the case is the rare appearance of multiple verrucous types of squamous cell carcinomas in a male patient, in Hurley Stage III, with a long HS disease duration, appearing on the perianal/gluteal region, being the first case report in our country. We suggest that a tumor screening should be done for all the patients with HS who have these risks.

Evaluation of risk in chronic cutaneous inflammatory conditions for malignant transformation

Skin carcinomas are the most common form of cancer, and every year thousands of people die from skin cancer-related malignancies. Chronic inflammation is linked to the development and progression of cancer in multiple organ systems - about 20% of all human cancers are a result of chronic inflammation - skin included. While acute inflammation under normal circumstances is a mechanism for host defence and tissue regeneration following insult by trauma or infection by pathogens, over the long term it can drive oncogenic transformation of epithelial cells and promote cancer development, growth and metastasis. Therefore, inflammatory conditions may put individuals at a higher risk to developing skin malignancies. Many skin conditions are characterized by chronic inflammatory processes. These conditions may be particularly susceptible to malignant transformation and predispose patients to develop skin malignancies. As more pathophysiology of chronic inflammatory skin conditions is unveiled, we find that many of these conditions are characterized by immune dysregulation and signalling that result in chronic activation and upregulation of pro-inflammatory chemokines and cytokines, leading to downstream processes that further exacerbate inflammatory processes and cause abnormal cell growth and apoptosis. Here, we review the major chronic cutaneous inflammatory diseases that may have an increased risk of skin malignancies, including atopic dermatitis, psoriasis, discoid lupus erythematosus, lichen planus, hidradenitis suppurativa, prurigo nodularis, lichen sclerosus, systemic sclerosis and morphea, chronic leg ulcers, seborrheic keratoses and basal cell carcinoma. We evaluate the evidence for increased incidence and prevalence, the risk factors associated, the populations at heightened risk and the best management practices.

Squamous cell skin carcinoma due to chronic sacrococcygeal diseases

Introduction/Objective. Sacrococcygeal region squamous cell cancers (SCC) due to chronic sacrococcygeal diseases of skin are rare malignancies. The anatomical relation with the anus represents a challenge for diagnosis and surgical treatment. The oncological treatment algorithm is still controversial. Here, we investigated the clinicopathologic features of skin cancer of the sacrococcygeal region in a total of 10 cases from a surgical oncology reference center. Methods. We retrospectively analyzed the patients who underwent surgery for sacrococcygeal region skin SCC between January 2010 and July 2020. Results. All patients were male, and the mean age was 52.9?10.5 years. In the etiology, five patients had hidradenitis suppurativa, 2 had Human papillomavirus associated condyloma (Buschke-Lowenstein tumor), and 3 had pilonidal sinus disease. The mean time between the development of the lesion and malignancy diagnosis was 21.7?5.8 years. In the preoperative evaluation, three patients had bone invasion. None of the patients had anal sphincter or rectal invasion. Also, no patient had lymph node metastasis or distant metastasis. Wide local excision (WLE) was performed in all patients; 3 of them with bone resection. Adjuvant chemoradiotherapy was applied to five patients. In a 28.5?13.7 months follow-up, local recurrence occurred in 5 patients and WLE has performed again in these patients. Of these 5 patients, 2 eventually became metastatic. Finally, 3 patients died due to disease and 6 patients are still free of diseases. Conclusion. Sacrococcygeal region SCCs may rarely develop after a long interval from hidradenitis suppurativa, pilonidal sinus disease, and condyloma acuminata. Anal sphincter-sparing WLE can be applied, but sphincter dysfunction may occur. The disease is associated with a high risk of relapse and poor survival.

Neoplastic Implications in Patients Suffering from Hidradenitis Suppurativa under Systemic Treatments

Hidradenitis suppurativa (HS) is a chronic, recurrent, inflammatory skin disease of the apocrine glands. It typically involves the axillary, submammary, genital, inguinal, perineal, and perianal regions. The development of abscesses, sinus tracts, and scars can lead to pain, scarring, disfigurement and decreased quality of life. HS is associated with a wide range of comorbidities. Several studies of co-occurrence of HS and nonmelanoma skin cancer suggest a causal relationship. In an attempt to assess the link between HS and cancer, we performed a systematic review of the current scientific knowledge through a PubMed-based literature search. Results show that HS could be associated with an overall risk of cancer and numerous specific cancers such as: nonmelanoma skin cancer (NMSC), hematologic malignancies, and metastatic cancer. Among NMSC, squamous cell carcinoma (SCC) is considered the most common complication arising in long-standing HS. Based on our review, we suggest that cautious surveillance and active intervention may be warranted in patients with HS. Moreover, an age-appropriate cancer screening should be offered to all patients, especially those who developed HS later in their life or in long-standing moderate to severe HS with multiple comorbidities.

Squamous cell carcinoma arising within hidradenitis suppurativa: a literature review

Squamous cell carcinoma (SCC) can present as a rare complication of longstanding hidradenitis suppurativa (HS) lesions. Limited data exist on characteristics and outcomes of SCC development within HS lesions. The purpose of this review is to conduct a literature review of previously reported cases of SCC development in pre-existing HS lesions. EMBASE and MEDLINE searches were conducted in OVID on June 25, 2020, to yield 59 studies. Of the 95 patients (mean age: 52.9 years) who developed a total of 122 SCCs within HS lesions, the majority were males (77.9%, n = 74/95). The most common sites of SCC were the gluteal region (47.5%, n = 58/122), the perianal region (18.9%, n = 23/122), and the genitals (13.9%, n = 17/122). The mean duration between HS onset and SCC development was 25.5 years. Of the patients that had outcomes reported, 54.0% (n = 34/63) experienced SCC metastasis, 43.1% (n = 28/65) experienced SCC recurrences, and 58.7% (n = 44/75) experienced a mortality outcome. The most common documented reasons for death included metastasis (34.1%, n = 15/44) and sepsis (13.6%, n = 6/44). Patients with longstanding HS lesions can develop SCCs with a high rate of metastasis and mortality. Thus, chronic HS lesions, especially in the gluteal, perianal, genital, and perineal regions, should be monitored regularly for timely SCC diagnosis and management.

Hidradenitis suppurativa: pathogenesis, clinical presentation, epidemiology, and comorbid associations

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that is clinically defined by lesions ranging from painful, deep seated nodules to abscesses, draining sinus tracts, and ultimately, irreversible fibrotic scars. While the etiology remains unclear, a number of mechanisms ranging from genetics to aberrations of the immune system have been proposed. In addition, HS has a number of associations and may occur in conjunction with several diseases that span a host of medical specialties. The estimated prevalence ranges are from 1% to 4%; however, a large degree of under-reporting and misdiagnosis of this condition likely underestimates its true clinical significance. The debilitating consequences of missed diagnoses or improper management leads to severe pain and irreversible cutaneous manifestations (i.e., fistulae, sinus tracts, disfiguring scarring). HS has been found to significantly impair patients' quality of life to a greater degree when compared with other skin conditions. Early recognition and treatment are critical for a favorable prognosis, and diagnostic delays may be related to variable presentations within numerous comorbidities. Here we provide an in-depth, clinical-based review of HS, highlighting the clinical presentation, pathophysiology, grading systems, epidemiology, and comorbidities, in hopes of shedding light on an often misunderstood disease and ultimately moving closer to a more conclusive understanding of its various presentations and association.

The management of hidradenitis suppurativa degenerating into squamous cell carcinoma: About three case reports

INTRODUCTION AND IMPORTANCE

Hidradenitis suppurativa (HS) is a chronic inflammatory and suppurative disease of the apocrine sweat glands. Its transformation into squamous cell carcinoma (SCC) is very rare.

CASE PRESENTATION

We describe 3 cases of males aged 57, 58 and 55-years-old. The diagnoses were confirmed by pathology examination in all cases. Two of our patients underwent extended and complete surgery. The first two patients died during the year after the diagnosis was established, the third one is still alive with no recurrence after one year of surgery.

CLINICAL DISCUSSION

Hidradenitis suppurativa mostly concerns perianal location and it targets mainly male patients with a multifactorial development. Surgical treatment consists of large excision. The SCC is associated with a high mortality rate.

CONCLUSION

Hidradenitis suppurativa needs early diagnosis and effective surgery. The transformation into squamous cell carcinoma is rare and and its management is challenging. Extended and complete excision is required with rigorous postoperative follow-up.

Cutaneous Squamous Cell Carcinoma in Patients with Hidradenitis Suppurativa

Background: Cutaneous squamous cell carcinoma (cSCC) is a rare complication of hidradenitis suppurativa (HS). Objectives: To conduct a systematic review and an individual patient data (IPD) meta-analysis to describe the clinical characteristics of HS patients developing cSCC and determine predictors of poor outcome. Methods: Medline/PubMed, Embase, and Web of Science were searched for studies reporting cSCC arising in patients with HS from inception to December 2019. A routine descriptive analysis, statistical hypothesis testing, and Kaplan-Meier survival curves/Cox proportional hazards regression models were performed. Results: A total of 34 case reports and series including 138 patients were included in the study. The majority of patients were males (81.6%), White (83.3%), and smokers (n = 22/27 reported) with a mean age of 53.5 years. Most patients had gluteal (87.8%), Hurley stage 3 HS (88.6%). The mean time from the diagnosis of HS to the development of cSCC was 24.7 years. Human papillomavirus was identified in 12/38 patients tested. Almost 50% of individuals had nodal metastasis and 31.3% had distant metastases. Half of the patients succumbed to their disease. Conclusions: cSCC is a rare but life-threatening complication seen in HS patients, mainly occurring in White males who are smokers with severe, long-standing gluteal HS. Regular clinical examination and biopsy of any suspicious lesions in high-risk patients should be considered. The use of HPV vaccination as a preventive and possibly curative method needs to be explored.

Questionnaire-based epidemiological study of hidradenitis suppurativa in Japan revealing characteristics different from those in Western countries

Hidradenitis suppurativa (HS) is a chronic relapsing skin disease localized mainly on the apocrine gland‐bearing areas. In Japan, HS is yet to be fully understood, and no criteria have been established for its diagnosis or severity assessment. The purpose of this study was to investigate and characterize HS in Japan. We conducted a nationwide questionnaire‐based study, in which Japanese diagnostic criteria were proposed. Question items included age, sex, disease duration, past history, family history, smoking status, disease severity scores (Hurley stage, modified Sartorius score and Physician Global Assessment [PGA] score), treatments, comorbidities and prognosis. We analyzed 300 patients (219 males and 81 females) diagnosed with HS based on our criteria. Average disease duration was 92.3 ± 6.82 months. Only 12 (4%) patients had a family history of HS. Disease severity was classified by PGA score (mild, 100 [33.3%]; moderate, 133 [44.3%]; severe, 34 [11.3%]; most severe, 29 [9.7%]) and Hurley stage (I, 69 [23%]; II, 109 [36.3%]; III, 121 [40.3%]). Disease severities based on PGA score and Hurley stage were positively correlated to modified Sartorius score using the Kruskal–Wallis test (P < 0.001, respectively). Patients with diabetes mellitus showed higher PGA scores (χ² = 10.977, P = 0.01185). Presence of axillary lesions related to higher PGA scores (χ² = 8.6378, P = 0.03452). The results in this study and previous studies indicate that Japanese HS patients have different backgrounds from those in Western countries, and are characterized by male predominance, higher incidence of Hurley stages II and III, higher PGA scores in patients with axillary lesions and much fewer familial cases.

Fatal outcome of malignant transformation of hidradenitis suppurativa: A case report and literature review

Squamous cell carcinoma arising in hidradenitis suppurativa (HS) is a rare albeit the most serious complication in HS, with a reported fatality of up to 42.9%. This calls for greater clinical awareness in patients with long-standing chronic HS.