Abstract Background Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease that may be complicated by irreversible lymphatic damage in long-standing, severe cases. Secondary genital lymphedema represents a rare but debilitating complication, significantly impairing physical function and quality of life. Although biologic therapies targeting key inflammatory pathways have improved disease control, paradoxical inflammatory reactions may occur and pose therapeutic challenges. Case report: We report a patient with severe HS complicated by progressive secondary genital lymphedema culminating in scrotal elephantiasis. After secondary failure of previous systemic treatment, therapy was switched to an IL-17 inhibitor brodalumab, which was complicated by the development of a paradoxical neutrophilic dermatosis with clinical features resembling pyoderma gangrenosum. Following treatment discontinuation, the patient was transitioned to infliximab, resulting in stabilization of both HS activity and inflammatory skin manifestations. Lymphoscintigraphy demonstrated impaired lymphatic drainage, and a comprehensive conservative lymphological approach, including rehabilitation therapy and manual lymphatic drainage, was initiated. The combination of targeted anti-TNF therapy and lymphatic rehabilitation led to a partial clinical improvement of genital edema and functional status. Nevertheless, persistent scrotal lymphedema reflected irreversible lymphatic damage. From a curative perspective, radical surgical treatment would likely represent the only definitive therapeutic option; however, the patient declined this approach. Conclusion This case highlights the complexity of managing advanced HS with secondary lymphatic complications and paradoxical reactions to biologic therapy. A multidisciplinary approach may improve symptoms, but its effectiveness is limited in advanced disease, where surgery is often necessary.
Ivanková et al. (Fri,) studied this question.