it includes hidradenitis suppurativa , acne conglobata , dissecting cellulitis of the scalp and pilonidal sinus . though each of these conditions are commonly encountered on their own , as a symptom complex follicular occlusion tetrad has rarely been reported in the literature . here we present a case of hidradenitis suppurativa in a 36-year - old male patient who also had the above mentioned associations . a 36-yeasr - old male patient presented to us with a history of recurrent boils since18 years . they initially started in the groin and buttocks with boils and gradually broke down to ooze pus . the boils healed with scarring after weeks to months . the process progressively started to involve the axillae and then the chest . the patient was treated with multiple antibiotics for over a decade that gave only symptomatic relief . the patient was diagnosed with pilonidal sinus at the age of 28 and he underwent surgery for the same . there was no family history of similar complaints , though his father suffered from psoriasis . on general examination , there were multiple areas of cicatricial alopecia on the scalp [ figure 1 ] and nodular scars on lower half of the face [ figure 2 ] . on query , the patient gave history of severe acne with nodules and pustules healing with scars on the face . he also had patchy swellings over the scalp region associated with pain in the past , which was diagnosed as folliculitis by a physician . patch of cicatricial alopecia on the occiput region of the scalp pustules , cysts and nodule - reminiscent of acne conglobata - on the lower half of the face on local examination , there were skin colored - to - erythematous nodules , grouped comedones and band like scars in the groin , buttocks , axillae and chest [ figure 3 and 4 ] . the patient had difficulty in lifting arms due to pain and scars in the axillae . multiple nodules , cysts and band like scars in the axillary region multiple nodules and pustules over the buttocks with surgical scar ( done for pilonidal sinus ) seen in the upper part of gluteal cleft a thorough general examination was followed by lab work - up . liver function tests and renal function tests were within normal limits and so was fbs , ppbs and fasting lipid profile . as the patient was obese , he was advised to follow a strict diet chart to lose weight . we also started him on oral isotretinoin 0.5 mg / kg body weight once daily . the patient came back after six weeks for prescription refill but was thereafter lost for follow - up . follicular occlusion tetrad is a condition that includes hidradenitis suppurativa ( hs ) , acne conglobata , dissecting cellulitis of the scalp and pilonidal sinus . hidradenitis suppurativa was first described in 1839 by velpeau ; verneuil gave it its name in 1854 and associated it with the sweat glands . later , hs was classified as a member of the follicular occlusion triad , along with acne conglobata and dissecting cellulitis of the scalp . in 1975 , pilonidal cyst was added as a member to this triad , forming the follicular occlusion tetrad . in 1989 , plewig and steger introduced the term acne inversa to substitute the term hs . hidradenitis suppurativa or acne inversa is a chronic , inflammatory , recurrent , debilitating skin disease that usually presents after puberty with painful , deep - seated , inflamed lesions in the apocrine gland - bearing areas of the body , most commonly the axillae , inguinal and anogenital regions . the exact pathogenesis of this group of diseases is unknown but evidence suggests that they share the same pathological process initiated by follicular occlusion . the pathogenesis and aetiology are unknown , but is thought to originate from poral occlusion of the pilosebaceous units . diagnostic criteria of hidradenitis suppurativa ( adopted by the 2 international conference on hidradenitis suppurativa , march 5,2009 , san francisco , ca us ) . 
 typical lesions , i.e. deep - seated painful nodules : blind boils in early lesions ; abscesses , draining sinus , bridged scars and  tombstonedouble - ended pseudo - comedones in secondary lesionstypical topography , i.e. axillae , groins , perineal and perianal region , buttocks , infra and inter mammary foldschronicity and recurrences . blind boils in early lesions ; abscesses , draining sinus , bridged scars and  tombstonedouble - ended pseudo - comedones in secondary lesions typical topography , i.e. axillae , groins , perineal and perianal region , buttocks , infra and inter mammary folds chronicity and recurrences . dissecting cellulitis(also called perifolliculitis capitis abscedens et suffodiens ) manifests with perifollicular pustules , nodules , abscesses and sinuses that evolve into scarring alopecia . it predominantly occurs in african american men between 20 - 40 years of age , but can occasionally affect other races and women too the tendency of dissecting cellulitis to cause severe alopecia , fluctuant nodules , and sinus tracts helps to distinguish it from acne keloidalis nuchae . culture of dissecting cellulitis does not produce a positive fungal culture and nuchal palpation does not reveal palpable lymph nodes , though reports have noted an inflammatory tinea capitis ( kerion ) that mimicked dissecting cellulitis in adolescents . its follicular papules and pustules spread peripherally , leaving central scarred patches of alopecia without nodules or sinuses . tufted folliculitis resolves with patches of scarring alopecia within which multiple hair tufts emerge from dilated follicular orifices . acne conglobata is an uncommon nodulocystictype of acne vulgaris that is often resistant to therapy . this disorder typically begins in adulthood and presents as numerous comedones , papules , pustules , nodules , abscesses , and draining sinus tracts involving the chest , back and buttocks . these lesions frequently become secondarily infected with gram - positive bacteria and often heal with scarring . pathology usually reveals inflammatory infiltrate around follicles , which can often disrupt the normal dermal architecture . acne conglobata is particularly disfiguring and socially detrimental to patients because of its chronicity , severity , and treatment challenge . acne conglobata ( ac ) resembles acne fulminans because both cause numerous inflammatory nodules on the trunk . unlike acne conglobata , large nodules of acne fulminans tend to become painful ulcers with overhanging borders surrounding exudative necrotic plaques that become confluent . the therapy of choice for ac includes isotretinoin 0.5 - 1 mg / kg for 4 - 6 months . simultaneous use of systemic steroids such as prednisone 1 mg / kg / d for 2 - 4 weeks may also prove beneficial , particularly if systemic symptoms are evident . oral tetracycline antibiotics should not be combined with oral isotretinoin because of an increased risk of pseudotumor cerebri . for treatment - resistant cases , dapsone 50 - 150 mg / d is recommended ; this treatment should be carefully monitored . pilonidal sinus was described as far back as 1833 when mayo described a hair - containing cyst located just below the coccyx . no specific laboratory studies or tests are needed to diagnose pilonidal disease and its sequelae or differentiate it from other disease entities ; it is a clinical diagnosis best elicited by history and physical examination findings . treatment of infection or abscess with oral antibiotics followed by surgical excision of the sinus is practiced .
follicular occlusion tetrad is a symptom complex consisting of four conditions having a similar pathophysiology . 
 it includes hidradenitis suppurativa , acne conglobata , dissecting cellulitis of the scalp and pilonidal sinus . 
 the exact pathogenesis of this group of disease is unknown but evidence suggests that they share the same pathological process initiated by follicular occlusion in apocrine gland bearing areas . 
 though each of these conditions is commonly encountered singly , follicular occlusion tetrad as a symptom complex has been rarely reported in the literature .