Supplementary Material for: Severe Penoscrotal Lymphedema in Hidradenitis Suppurativa: A Case Series

Introduction: Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease characterized by recurrent painful nodules, abscesses, and sinus tracts in apocrine gland-bearing areas. Penoscrotal lymphedema represents a rare but devastating complication, predominantly affecting patients with longstanding Hurley Stage III disease.
Case Presentation: We present three cases of severe penoscrotal lymphedema in middle-aged males with longstanding HS. Case 1 involved a 42-year-old smoker with 10-year HS history who developed progressive lymphedema with violaceous nodules and sinus tracts over 5 years. Case 2 involved a 45-year-old male with Fitzpatrick skin phototype IV and adolescent-onset HS who developed massive scrotal lymphedema with characteristic verrucous lymphostasis and adult-acquired buried penis over 8 years. Case 3 involved a 53-year-old male with 16-year HS history who developed massive penoscrotal lymphedema complicated by secondary (AA) amyloidosis with chronic kidney disease and proteinuria. All patients demonstrated profound quality of life impairment and underwent systematic exclusion of alternative etiologies. Treatment included systemic antibiotics and TNF-alpha inhibitors (adalimumab), with variable clinical response.
Conclusion: These cases highlight the importance of early recognition, as timely biologic therapy may prevent progression to irreversible complications requiring surgical intervention. Lymphedema in HS requires multidisciplinary management involving dermatology, plastic surgery, urology, nephrology, and psychological support services.