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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 26  |  Issue : 2  |  Page : 67-70

Surgically treating hidradenitis suppurativa that does not respond to medical treatment


1 Diskapi Yildirim Beyazit Training and Research Hospital, Department of Plastic, Reconstructive and Aesthetic Surgery, Ankara, Turkey
2 Dr. Ersin Arslan Training and Research Hospital, Plastic, Reconstructive and Aesthetic Surgery Clinic, Gaziantep, Turkey
3 Elmas Plastic, Reconstructive and Aesthetic Surgery Center, Ankara, Turkey

Date of Web Publication13-Apr-2018

Correspondence Address:
Dr. Ugur Horoz
Dr. Ersin Arslan Training and Research Hospital, Plastic, Reconstructive and Aesthetic Surgery Clinic, Eyupoglu Mah, Hurriyet Cd., 27010 Sahinbey, Gaziantep
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.TJPS_6_17

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  Abstract 


Objective: Hidradenitis suppurativa is a chronic inflammatory disease of the skin involving the infundibular terminal follicles in the areas of the body containing apocrine glands. The pathology leads to purulent drainage and pain, abscesses, hypertrophic scars, and sinus formation in the affected areas. Treatment options for the disease include retinoid, antibiotics, antiandrogens, immunosuppressive agents, laser therapy/phototherapy, and surgery. This study aimed to assess the results of surgical treatment in patients who could not be treated medically. Materials and Methods: This study reviewed twenty patients who did not heal with medical treatment in the last 5 years. Results: Defect reconstructions were performed using grafts on eight patients, flaps on five patients, and primary closure on seven patients. One patient had a long-term recurrence. Conclusion: In the researchers' experience with different reconstruction methods and the wide excision of the disease, clinically satisfactory results can be achieved in cases that do not heal with medical treatment.

Keywords: Hidradenitis suppurativa, medical treatment, surgical treatment


How to cite this article:
Keles MK, Horoz U, Seven E, Karamursel S, Tellioglu AT. Surgically treating hidradenitis suppurativa that does not respond to medical treatment. Turk J Plast Surg 2018;26:67-70

How to cite this URL:
Keles MK, Horoz U, Seven E, Karamursel S, Tellioglu AT. Surgically treating hidradenitis suppurativa that does not respond to medical treatment. Turk J Plast Surg [serial online] 2018 [cited 2019 Jul 16];26:67-70. Available from: http://www.turkjplastsurg.org/text.asp?2018/26/2/67/230119




  Introduction Top


Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the apocrine glands, which mostly occurs in the axillar, inguinal, perianal, and perineal regions, as well as the inframammary fold and the intermammary cleft.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10] It was first described by Velpeau in 1839.[1],[2],[3],[4],[7],[8],[9],[10] Histopathology of the disease is not exactly known; however, bacterial superinfection develops subsequent to follicular gland occlusion and concomitant infection.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11] A combination of genetic, metabolic, traumatic, environmental, and hormonal factors is estimated to be responsible for its etiology.[3] Although its etiology is unclear, smoking and obesity are known to impact the progression of HS.[3] Clinically, concomitant pustules and presence of multiple comedones can lead to disturbing symptoms.[7] There are studies that indicate the interleukin-2 receptor as a meaningful biomarker besides C-reactive protein.[6] While local care and medical treatment can be effective in suppression, surgical excision of the infected glands is the fundamental treatment. After studies demonstrated an association between pro-inflammatory cytokines and HS, biologic monoclonal antibodies were used in its treatment. This study aims at evaluating the reconstruction results achieved with surgical excision performed together with flap or graft in hidradenitis cases, in which medical treatment was unsuccessful.


  Materials and Methods Top


Twenty patients who presented to our clinic between October 2011 and August 2016 with chronic masses with discharge were included in the study. All patients were diagnosed with hidradenitis and underwent surgery subsequent to unsuccessful medical treatment. All patients were clinically diagnosed with HS after consulting the dermatology department. Surgical indication was established with the recommendations of the dermatology department. All patients were operated on under general anesthesia following the routine preparations. The surgical procedure performed involved the excision of all infected tissues together with side and base margins. Patients were hospitalized for postoperative follow-up for different lengths of time depending on the procedure performed. While dressing was monitored daily in patients treated with graft procedures, wound site was redressed daily in other patients. Patients were closely followed up after discharge for early complications such as wound site infection, wound dehiscence, and graft loss and rehospitalized for treatment if recurrence or local complications were observed. Patients who did not have any problems in the early postoperative follow-up period were monitored through routine visits in the 1st, 3rd, and 6th months. Subsequent visits were scheduled if patients had further complaints. Those who did not adhere to follow-up visits were excluded from the study. All patients were analyzed in terms of age, gender, localization of lesion, presence of comorbidities, size of lesion, and reconstruction technique. The study was conducted according to the latest amended version of the Declaration of Helsinki and consent was obtained from all patients.


  Results Top


Twenty-four patients who were treated in our clinic between October 2011 and August 2016 were evaluated. Four patients who did not adhere to routine follow-up visits were excluded from the study. Of the 20 patients included in the study, 11 were male and 9 were female. Their ages ranged from 13 to 68 years, with a mean of 40.3 years. Thirty lesions of twenty patients were surgically treated. Of the 20 patients, lesions were bilateral axillary in 9, sternal in 3, unilateral axillary in 3, bilateral axillary and sternal in 1, bilateral axillary and postauricular in 1, bilateral axillary and inguinal in 1, inguinal in 1, and gluteal and axillary in 1 [Table 1]. Thirteen patients had multiple lesions (65%). Six patients had comorbidities. Of these six patients, two had diabetes mellitus and four had hypertension [Table 1]. Rate of comorbidities among the patients is 30%. Sizes of surgical defects ranged from 10 to 180 cm2 [Table 1]. Defects were reconstructed with fasciocutaneous flap in five patients [Figure 1]. Defect areas were primarily closed in seven patients [Figure 2] and grafting was performed in eight patients [Figure 3] and [Table 1]. Wound dehiscence due to infection was observed in two patients in the early period. Recurrence occurred in one patient (5.5%) after the routine follow-up period in month 22.
Table 1: Summary of patient data

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Figure 1: In a patient surgically treated for axillary hidradenitis, the defect was reconstructed with a flap: (a) preoperative view, (b) intraoperative view, and (c) view after reconstruction with flap

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Figure 2: In a patient surgically treated for sternal hidradenitis, the defect was closed primarily: (a) preoperative view, (b) intraoperative view, and (c) view after suturing

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Figure 3: In a patient surgically treated for axillary hidradenitis, the defect was reconstructed with a graft: (a) preoperative view, (b) intraoperative view, and (c) view after reconstruction with grafting

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  Discussion Top


Prevalence of HS ranges approximately from 1% to 4%.[1],[2],[3],[10] Some studies associate HS with metabolic disorder and hormonal derangement because it is less common before puberty and after andropause/menopause. In descending order of involvement, it can occur on the skin of the axillary, inguinal, perianal and perineal regions, the inframammary fold and the intermammary cleft, the buttocks and the pubic region, the torso, the scalp, the retroauricular region, and the eyelid. Hurley has classified the disease into three groups:[2] Stage I: Abscess formation, single or multiple, without sinus tracts and cicatrization; Stage II: Recurrent abscesses with tract formation and cicatrization; and Stage III: Diffuse or near-diffuse involvement or multiple interconnected tracts and abscesses across the entire area.[4],[9] Regardless of its etiology, abscesses, skin fistulae, and discharge developing after the infection of the apocrine glands followed by bacterial superinfection can lead to serious morbidities. Due to its localization and progression, patients consult gynecology, surgery, immunology, infectious diseases, dermatology, or plastic surgery departments.[2],[10] A simple surgical procedure with incision and drainage will dramatically reduce symptoms, but increase recurrence risk.[9] Studies and evaluations of literature reports suggest that the disease is most effectively treated with a wide surgical excision followed by reconstruction performed with mostly a flap, or a graft, and by primary closure.[1],[2],[3],[4],[8],[9] In cases where medical treatment proves ineffective, surgical removal of all affected apocrine glands is considered as the fundamental treatment of HS.[4]

Success rates of nonsurgical methods in the treatment of the disease are not exactly known due to limited reporting. Surgical treatment seems to be the gold standard and a highly curative approach. Nevertheless, there are reports of effective nonsurgical treatment methods in the literature. While Chinniah and Cains report biologic antibodies, John et al. report laser treatment and Miller et al. report usage of isoniazid with successful outcomes.[1],[7],[11] In a large series of patients who were surgically treated, Kohorst et al. highlight successful outcomes in the management of the disease and low recurrence rates regardless of age, location, and stage of disease or other factors.[9] Falola et al. report the superiority of a surgical treatment combined with biologic agents over surgical treatment alone in the treatment of HS, whether primary or recurrent.[3] Besides conventional methods of medical treatment, reports from the past few years describe laser treatment and treatment with biologic agents such as adalimumab and infliximab with varied success rates.[1],[7] Given that granuloma is also seen in 25% of HS cases, its relation with other granulomatous diseases, such as Crohn's disease and tuberculosis, is being investigated and medical treatments used in these diseases are being studied.[11]

Similar to the case series reported by Humphries et al., the patients in our case series had previously received medical treatment without achieving curative outcomes. All patients in our series were Stage II and Stage III according to Hurley's classification. We treated all our patients surgically, with no additional medical treatment, and no recurrences were encountered in any of the patients except one in the absence of a medical approach.


  Conclusion Top


The main goal in the surgical treatment of HS is the wide surgical excision of the lesion followed by a reconstruction to eliminate contracture with acceptable esthetic outcomes. Whereas many approaches have been published, no clear treatment algorithms are defined for HS. Based on our evaluations of the reports available in the literature and our clinical experiences, we recommend surgical excision and suitable reconstruction as an effective approach in the treatment of cases with Hurley Stage II and III (moderate and severe) that have been unsuccessfully treated with medical management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chinniah N, Cains GD. Moderate to severe hidradenitis suppurativa treated with biological therapies. Australas J Dermatol 2014;55:128-31.  Back to cited text no. 1
[PUBMED]    
2.
Collier F, Smith RC, Morton CA. Diagnosis and management of hidradenitis suppurativa. BMJ 2013;346:f2121.  Back to cited text no. 2
    
3.
Falola RA, DeFazio MV, Anghel EL, Mitnick CD, Attinger CE, Evans KK, et al. What heals hidradenitis suppurativa: Surgery, immunosuppression, or both? Plast Reconstr Surg 2016;138:219S-29S.  Back to cited text no. 3
    
4.
Humphries LS, Kueberuwa E, Beederman M, Gottlieb LJ. Wide excision and healing by secondary intent for the surgical treatment of hidradenitis suppurativa: A single-center experience. J Plast Reconstr Aesthet Surg 2016;69:554-66.  Back to cited text no. 4
    
5.
Ingram JR. Hidradenitis suppurativa outcome measures and treatment goals. Br J Dermatol 2014;171:1293-4.  Back to cited text no. 5
    
6.
Jemec GB. Biomarkers in hidradenitis suppurativa. Br J Dermatol 2013;168:1151-3.  Back to cited text no. 6
    
7.
John H, Manoloudakis N, Stephen Sinclair J. A systematic review of the use of lasers for the treatment of hidradenitis suppurativa. J Plast Reconstr Aesthet Surg 2016;69:1374-81.  Back to cited text no. 7
    
8.
Karagiannidis I, Nikolakis G, Sabat R, Zouboulis CC. Hidradenitis suppurativa/Acne inversa: An endocrine skin disorder? Rev Endocr Metab Disord 2016;17:335-41.  Back to cited text no. 8
    
9.
Kohorst JJ, Baum CL, Otley CC, Roenigk RK, Schenck LA, Pemberton JH, et al. Surgical management of hidradenitis suppurativa: Outcomes of 590 consecutive patients. Dermatol Surg 2016;42:1030-40.  Back to cited text no. 9
    
10.
Menderes A, Sunay O, Vayvada H, Yilmaz M. Surgical management of hidradenitis suppurativa. Int J Med Sci 2010;7:240-7.  Back to cited text no. 10
    
11.
Miller IM, Dufour DN, Jemec GB. Treatment of hidradenitis suppurativa: Is oral isoniazid an option? J Dermatolog Treat 2012;23:128-30.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

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