Advanced hidradenitis suppurativa (HS) as a sentinel manifestation of undiagnosed diabetes in a previously healthy male: a case report.

Introduction and importance: Hidradenitis suppurativa (HS) is a chronic, long-term inflammatory disorder of the skin that affects pilosebaceous-apocrine units. Follicular occlusion within these units leads to follicular rupture, which triggers immune response, followed by bacterial colonization, and ultimately chronic sinus tract formation presenting with painful lumps, draining sinuses, and scarring. It is often diagnosed late and is associated with metabolic comorbidities, such as obesity and diabetes. This case of HS was the sentinel manifestation of previously undiagnosed type 2 diabetes in a seemingly healthy 47-year-old male with bilateral axillary Hurley stage III disease. Presentation of case: A 47-year-old obese male presented with 1.5 years of bilateral axillary nodules, draining sinuses, scarring, and mild constitutional symptoms, more marked on the right side. Labs revealed leukocytosis and an elevated HbA1c of 12.8%, confirming the status of diabetes. Treatment involved right-sided wide excision with V-Y flap reconstruction and left-sided incision and drainage under IV cefazolin and metronidazole. Post-operative glycemic control was achieved by insulin therapy and analgesia for symptom relief. Clinical discussion: This case highlights HS as a systemic inflammatory condition. Although the patient had no smoking history or family history of HS, obesity may have contributed to severity of disease. Prior literature shows that HS patients have two to three times higher odds of type 2 diabetes mellitus (T2DM). The Hurley stage III diagnosis underscores the importance of essential metabolic screening, especially in older or obese individuals. Conclusion: HS is a marker of metabolic disease, whether presented in early or late stages. A multidisciplinary approach can optimize early diagnosis and recovery. Routine screening of T2DM in severe HS cases is necessary to prevent complications, recurrence, and to improve patient outcomes.