Differential Diagnosis Between Perianal Crohn’s Disease and Hidradenitis Suppurativa: A Challenging Teamwork

Abstract

Hidradenitis suppurativa (HS) is a rare, debilitating skin disease characterized by the presence of recurrent tender subcutaneous nodules that develop into abscesses and fistulae. Isolated perineal Crohn's disease (CD) is unusual, diagnosis can be difficult, and distinction from HS is a challenge for the gastroenterologist. The aim of this work was to determine the criteria that distinguish perineal CD from perineal HS. Four patients with isolated perineal CD and three with perineal HS were included. Rectal or skin biopsies of all CD patients showed granulomas. No granulomas were found for HS. Fistulae were present in 4/4 CD, extended to the anal canal. All patients with HS had gluteal abscesses. They were bilateral in all cases, superficial. Perineal lesions management should involve a multidisciplinary approach in order to make an accurate diagnosis and ultimately to give the best and most effective treatment.

Nonfistulizing Perianal Crohn's Disease

“…Biopsy of the affected area can be useful, as the presence of granulomas supports a diagnosis of CD. 60 Furthermore, isolated perianal CD is rare-so findings consistent with HS in the absence of intestinal symptoms are unlikely to represent CD. Perianal abscesses or sinuses that are superficial are common in HS where fistulas or rectal involvement are more common in CD.…”

“…Perianal abscesses or sinuses that are superficial are common in HS where fistulas or rectal involvement are more common in CD. 60,61 Magnetic resonance imaging can be useful in distinguishing the two, with one study reporting 100% sensitivity in distinguishing HS from CD in cases of HS where there was posterior involvement, bilaterality of disease and absence of rectal wall thickening. 61 CD and HS overlap in both pathological features and genetic susceptibility.…”

“…64,65 Consequently, both diseases can be effectively treated with anti-TNF-α agents, although higher doses than typical may be needed for disease control. 60 Interestingly, there have been case reports and small case series of paradoxical development of HS in CD patients treated with anti-TNF-α medications. 66 The underlying mechanism for this observed paradox is yet to be uncovered.…”