Prashant Verma and Namrata Chhabra

Department of Dermatology & STD, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Delhi, India. E-mail: drprashant_derma@yahoo.co.in

Accepted December 24, 2011.

Sir,

We read with interest the article by Tanaka et al. (1). However, we conclude that the patient could have botryomycosis rather than hidradenitis suppurativa. Botryomycosis is characterized by chronic, purulent and granulomatous lesions of the dermis and subdermal tissue. Morphologically, it is characterized by plaques with sinuses, superficial pustules and crusts (2). It is reported that the patient had a plaque with central purulent draining sinuses with a deep-seated nodule, and that the peripheral part had mild scar formation over the limb. Limbs are the most common sites of affliction (2). In contrast, hidradenitis suppurativa classically affects the pilosebaceous-apocrine unit of the axillary, inguinal and mammary region in females (3). Escherichia coli and Staphylococcus epidermidis were confirmed on culture of the discharge in the case under consideration, and these are well documented in the aetiology of botryomycosis (4). Furthermore, the lesion was refractory to antibiotics and responded to surgical resection, and this may also be the case for botryomycosis.

REFERENCES

Hisashi Uhara and Ryuhei Okuyama

Department of Dermatology, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, 390-8621 Japan. E-mail: rokuyama@shinshu-u.ac.jp

Sir,

We thank Dr Verma for his interest in our paper. The most important point for diagnosis is whether bacterial infection was predominant in this eruption. Botryomycosis is an uncommon, chronic, granulomatous bacterial infection affecting the skin and viscera. The key to the diagnosis is the presence of grains containing masses of bacteria within discharge and/or biopsied tissues. However, we did not detect grains in the discharge or biopsied skin. Furthermore, bacterial cultures from the discharge isolated only a small number of colonies of Escherichia coli and Staphylococcus epidermidis, which was consistent with the fact that the lesion did not respond to disinfection with chlorhexidine gluconate or oral antibiotics. These facts suggested that the lesion was an inflammatory disease rather than a bacterial infection. Hidradenitis suppurativa is now thought to be an inflammatory disease originating from follicular occlusion, and it is not surprising that hidradenitis suppurativa developed in other than apocrine gland-rich regions.