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Pyoderma gangrenosum, severe acne, and suppurative hidradenitis (PASH) syndrome can prove refractory to treatment and is characterized by relapses and recurrences. The combination of antibiotic therapy and surgery can produce success in the management of the syndrome. Acute treatment is required, but maintenance therapy is also necessary to prevent disease relapse. The response to antibiotic therapy is hypothesis generating, raising the issue of a modified host response. To date, anecdotal reports support the use of surgery and medical therapy, but controlled investigations with extended follow-up are necessary to substantiate preliminary data observed with individual cases., (Copyright © 2015 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

The recent innovative interventions in the acnes (acne vulgaris, acne rosacea and acne inversa) have not occurred in their management; rather the major changes are occurring in how the disorders and the individual lesions are seen to originate and develop. To finalize the optimal management of each of the acnes will ultimately require that every step in the aetiopathogenesis described and postulated here will need to be tested, validated, and then appropriately countered with environmental and lifestyle adjustments that will lead ultimately to prevention of 'the blight of youth' and its variants.

The pathogenesis of acne inversa is follicular hyperkeratosis with occlusion and rupture. The subsequent acute inflammatory response leads to erythema, abscesses, fistulas, sinus tracts and scarring. Sites of predilection are the intertriginous regions. Many conservative therapies have only a supportive character. Therapy of choice is the early surgical intervention with complete excision of the involved areas, as conservative therapy is at best supportive. Although healing by second intention is preferred, all variations of flaps and grafts have been used. Usually the course of acne inversa lasts years until patients elect surgery after a physical and psychological odyssey.