Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2025;15(1):4812 1 Hidradenitis Suppurativa-Like Tuberculosis: A Warning for Dermatologists José Paulo Ribeiro Junior¹, Hugo Macêdo de Moura¹, Maria do Carmo Araujo Palmeira Queiroz¹, Roberta Marinho Falcão Gondim¹ 1 University Hospital Onofre Lopes, Department of Dermatology. Federal University of Rio Grande do Norte, Natal, Brazil Key words: Hidradenitis Suppurativa; Tuberculosis; Extrapulmonary tuberculosis; Abscess Citation: Ribeiro Junior JP, Macêdo de Moura H, do Carmo Araujo Palmeira Queiroz M, Marinho Falcão Gondim R. Hidradenitis Suppurativa-Like Tuberculosis: A Warning for Dermatologists. Dermatol Pract Concept. 2025;15(1):4812. DOI: https://doi.org/10.5826/ dpc.1501a4812 Accepted: October 2, 2024; Published: January 2025 Copyright: ©2024 Ribeiro Junior et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: José Paulo Ribeiro Júnior, Avenida Nilo Peçanha, 620. Department of Dermatology. Natal, Brazil; Phone: +5584991531608. E-mail: josepaulojr@outlook.com Introduction Tuberculosis (TB) ranks among the leading causes of death worldwide and because of this alarming statistic, its ex- trapulmonary forms are also becoming more prevalent [1,2]. The cutaneous presentations are highly variable, ranging from papules to ulcero-vegetative lesions, posing a challenge for dermatologists who may confuse it with other common conditions such as hidradenitis suppurativa (HS) [2,3]. This paper aims to describe the correlation between these often neglected diseases and their potential diagnostic confusion. Case Presentation A 17-year-old male student without comorbidities, presented to the Dermatology Outpatient Clinic with painful nodules that had been abscessing and draining purulent discharge in the thoracic and axillary regions for the past 8 months. De- spite previous antibiotics prescribed by general practitioners, there had been no improvement. He denied fever, weight loss or any decline in general health. On examination, he had a painful nodule in the right axilla and ulcerations in the anterior axillary line, symmetrically located on both sides. In the sternal region, four ulcerated plaques with granulation tissue and undermined and violaceus borders (Figure 1). The hypothesis of HS was considered but due to atypical presen- tation, differential diagnoses with ulcerovegetative pattern diseases were regarded. The patient returned with negative cultures but with a positive molecular rapid test (MRT) for tuberculosis, confirming the diagnosis of cutaneous TB. Standard anti-tuberculosis chemotherapy was initiated and maintained for six months, resulting in the complete resolu- tion (Figure 2). Conclusions The mimicking of cutaneous TB as HS was also noted by other authors [4,5]. However, in this case, further investi- gation was carried out at the initial assessment due to the presence of advancing ulcerations, the lack of involvement 2 Research Letter | Dermatol Pract Concept. 2025;15(1):4812 of other cutaneous folds, and no improvement with tetra- cyclines. The clinical manifestation of the disease was con- sistent with the scrofuloderma subtype, characterized by nodules that coalesce into fistulas, draining purulent mate- rial and lead to ulceration [6]. However, it drew attention due to its unusual presentation with multiple and symmet- rical lesions, an atypical manifestation for an infectious disease, resembling inflammatory conditions. Another key aspect is that the patient, a healthy young individual, has not exhibited pulmonary or systemic symptoms, distinguishing this case from previously reported ones. Melo and colleagues also documented scrofuloderma following therapeutic attempts for pyoderma gangrenosum and HS [4]. A case involving deeper tissues has also been pre- sented by Ermertcan and colleagues who described a severe case of Pott disease (vertebral tuberculosis) that was mis- takenly treated as HS [5]. The diagnostic confusion can be explained by the clinical similarities, highlighted by the HS criteria, which include morphology, distribution of lesions (intertriginous areas), and a protracted course. Given the multiple presentations, tuberculosis may mimic more prev- alent diseases, including HS but also bacterial abscesses, ter- tiary syphilis, and tumor metastases [2,6]. This study emphasizes the need to reconsider atypical HS cases, regardless of systemic symptoms or immunocom- promised status. Due to the surgical nature of HS treatment and the emerging immunosuppressive therapies, which can exacerbate and spread pre-existing TB, assertiveness is criti- cal. Whilst we do not recommend biopsy in all cases of HS, caution is advised, emphasizing that diagnostic testing for TB should be performed in atypical presentations. References 1. Chen Q, Chen W, Hao F. Cutaneous tuberculosis: A great imitator. Clin Dermatol. 2019;37(3):192–199. DOI: 10.1016 /j.clindermatol.2019.01.008. PMID: 31178102. 2. Khadka P, Koirala S, Thapaliya J. Cutaneous Tuberculosis: Clinicopathologic Arrays and Diagnostic Challenges. Dermatol Figure 1. A 17-year-old man presenting ulcers with purulent exudate drainage. (A) Nodule and ulcer on right armpit. (B) Ulcer on left armpit. (C) Ulcers on sternal region. Figure 2. A 17-year-old man treated for cutaneous tuberculosis. Scars from ulcers after 3 months of standard polychemotherapy. (A) Right armpit. (B) Left armpit. (C) Sternal region. Research Letter | Dermatol Pract Concept. 2025;15(1):4812 3 5. Ermertcan AT, Öztürk F, Gençoğlan G, İnanir I, Özkütük N, Temiz P. Pott’s disease with scrofuloderma and psoas abscess mis- diagnosed and treated as hidradenitis suppurativa. J Dermato- log Treat. 2011(1):52-54. DOI: 10.3109/09546630903443365. PMID: 20536275. 6. Brito AC, Oliveira CMM, Unger DAA, Bittencourt MJS. Cutane- ous tuberculosis: epidemiological, clinical, diagnostic and ther- apeutic update. Dermatol. pract. concept. 2022;97(2):129-144. DOI: 10.1016/j.abd.2021.07.004. PMID: 34996655. PMCID: PMC9073256. Res Pract. 2018:1–9. DOI: 10.1155/2018/7201973. PMID: 30111996. PMCID: PMC6077618. 3. Franco-Paredes C, Marcos LA, Henao-Martínez AF, et al. Cuta- neous Mycobacterial Infections. Clin Microbiol Rev. 2018;32(1): e00069-18. DOI: 10.1128/CMR.00069-18. PMID: 30429139. PMCID: PMC6302357. 4. Mello RB, Vale ECSD, Baeta IGR. Scrofuloderma: a diag- nostic challenge. An Bras Dermatol. 2019(1):102-104. DOI: 10.1590/abd1806-4841.20188560. PMID: 30726475. PMCID: PMC6360976.