British Journal of Dermatology (1992) 126. 523-529.

Correspondence Crohn's disease in association with hidradenitis suppurativa SIR. We were interested to read the report by Ostlere, et a/.' describing three cases of hidradenitis suppurativa (HS) in Crohn's disease. We wish to add further support to this association by reporting two similar cases. We are also aware of an earlier report of Crohn's disease occurring in a 1 7-yearold Black man in association with a seronegative arthropathy and the 'follicular occlusion triad' of severe acne, HS and dissecting cellulitis ofthe scalp.^ No details were provided ofthe distribution ofthe HS. but the Crohn's disease affected both the large and small bowel. The first case involved an obese Jamaican male who developed multiple ischiorectal and groin abscesses with sinus formation at the age of 19 years. This was followed 6 months later by similar involvement of both axillae. There was no preceding history of acne and he denied any bowel symptoms. Initial skin biopsies from the perianal area were reported as showing abscess formation with chronic inflammation. A clinical diagnosis of perineal Crohn's disease was suspected and during the next year, despite three incision and drainage procedures he continued to develop new abscesses. Investigation of his large bowel, by colonoscopy and biopsy, showed numerous epithelioid granulomata in the lamina propria with extension into the submucosa, consistent with Crohn's disease. Treatment with sulphasalazine, metronidazole. prednisolone and azathioprine was unhelpful and a hemicolectomy and ileostomy were therefore performed. Despite this procedure no improvement was seen in the perineal suppuration. In view of the poor response of the cutaneous lesions to treatment of the Crohn's disease further skin biopsies were obtained and reviewed. These subsequent biopsies were compatible with chronic suppuration due to HS. Eighteen months after presentation he developed a subacute demyelinating peripheral neuropathy possibly related to the chronic suppuration or Crohn's disease. His recovery was complicated by the development of sacral osteomyelitis. The HS has been controlled by surgical excision and split-skin grafts. Case 2 was a 29-year-old female who presented with a 6year history of recurrent painful abscesses predominantly of the axillae, but also occasionally involving the groins. There was no premenstrual flare ofthe lesions. A clinical diagnosis of HS was made and she was treated with minocyline 100 mg twice daily and topical erythromycin, with initial success. One year after presentation she developed symptomatic Crohn's disease with extensive involvement of the large bowel, and a hemicolectomy was required. She continued to develop abscesses and sinuses in the axillae and a skin biopsy was consistent with HS, thus excluding cutaneous Crohn's disease. Subsequent control of the HS was achieved with combined cyproterone acetate and ethinyloestradiol. These cases support the association between HS and Crohn's disease. However two important differences were seen in our cases compared with those of Ostlere et al,' Firstly, unlike the previous cases, the HS in our patients preceded the diagnosis of

Crohn's disease (by 1 and 6 years). Secondly, axillary involvement was a prominent feature in both of our cases. In our cases, and those previously reported, the Crohn's disease has been severe and has mainly involved the large bowel. All required a colectomy for their gastrointestinal disease. When extensive HS affects the perineal region, as in the first case, it may be difficult to distinguish between HS and Crohn's disease either by clinical or histological criteria. The presence of HS may therefore go unrecognized. However, additional involvement of the axilla favours a diagnosis of HS as metastatic Crohn's disease of the skin usually affects the lower extremities' and has not been reported at this site. The role of local factors in HS has been emphasized"* although the association with Crohn's disease suggests that HS may be a manifestation of underlying disease. Further studies are needed to test the specificity of this association. Department of Dermatology, Ealing Hospital,

N.P.BURROWS R.RUSSELL JONES

Uxbridge Road, Southall, Middlesex UBl 3HW, U,K,

References 1 Ostlere LS. Langtry j AA. Mortimer PS. Staughiton RCD. Hidradenitis suppurativa in Croiin's disease. Br J Dermatol 1991: 125: 384-6. 2 Ellis Bl. Siiier CK. Leisen J] et al Acne-associated spondylarthropathy: radiograpiiic features. Radiology 1987: 162: 541-5. 3 Siium DT, Guenther L. Metastatic Crohn's disease. Arch Dermatol 1990: 126: 645-8. 4 Dvorak VC. Root RK. MacGregor RR. Host-defence mechanisms in iiidradenitis suppurativa. Arch Dermatol 1977: 113: 450-3.

Norwegian scabies and herpes simplex in a patient with chronic lymphatic leukaemia and hypogammaglobulinaemia SIR, Norwegian scabies is a crusted non-itchy rash caused by massive infestation with the mite Sarcoptes scahiei. This was originally described in patients with Down's syndrome' and leprosy^ and more recently in patients who are immunosuppressed by leukaemia,' drugs'* or HIV infection.^ We report a case of focal crusted scabies occurring on the face of a patient with chronic lymphocytic leukaemia (CLL) and concurrent herpes simplex. A 67-year-old man with a 10-year history of CLL, treated with intermittent chlorambucil and prednisolone, presented with a crusted lesion on his upper lip at the site of a recent herpes simplex infection. He had suffered from recurrent facial herpes for 3 years and had had an attack of itchy scabies 2 years previously. At the time of presentation he was taking oral acylovir and prednisolone each day. He had been receiving regular infusions of gammagiobulin as he suffered from recurrent chest infections and was hypogammaglobulinaemic.

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Crohn's disease in association with hidradenitis suppurativa.

British Journal of Dermatology (1992) 126. 523-529. Correspondence Crohn's disease in association with hidradenitis suppurativa SIR. We were interest...
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