Photo Rounds

Painful lumps on back

A 53-year-old man sought care for painful lumps on his back. The family physician (FP) that saw him noted many open comedones and cysts on his back, as well as scars on the axilla, face, and scalp. The patient's medical history was notable for hypertension, which was well controlled.

What's your diagnosis?


The FP recognized that this patient was suffering from the follicular occlusion triad, which includes acne conglobata on the back, hidradenitis suppurativa, and dissecting cellulitis of the scalp. Some adult males (and occasionally females) have acne conglobata that takes the form of open comedones and cystic nodules that are found on the chest, shoulders, back, buttocks, and face. However, in some patients (like this one), acne conglobata is part of a follicular occlusion triad including hidradenitis suppurativa and dissecting cellulitis of the scalp.

Hidradenitis suppurativa causes purulent nodules, cysts, and sinus tracts in the axilla, groin, buttocks, and the breast area of women. Dissecting cellulitis of the scalp is a form of scarring alopecia that creates sinus tracts filled with pus on the scalp.

Treatment choices available for the whole follicular occlusion triad include oral isotretinoin (often known by the discontinued brand name Accutane), acitretin, multiple oral antibiotics, and some of the same biologic agents used to treat psoriasis. Unfortunately, this disease is hard to manage and impossible to cure.

Fortunately for this patient, the hidradenitis suppurativa and dissecting cellulitis weren’t active when he sought care. The patient found the cysts on his back to be tender and painful, but was not worried about the blackheads (open comedones). The FP offered to excise the tender cysts on his back and referred the patient to a skin specialist for the follicular occlusion triad. The patient returned to the FP’s office for 2 cyst excisions and scheduled an appointment with a skin specialist.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R. Acne vulgaris. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:651-658.

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