Surgery for Hidradenitis Suppurativa Treatment & Management

  • Author: Naveen Pokala, MBBS, MS, FRCS; Chief Editor: John Geibel, MD, DSc, MA   more...
 
Updated: Nov 18, 2011
 

Medical Therapy

Treatment depends upon the stage of the disease. Early lesions are usually treated by medical therapy, whereas the patient with long-standing indolent disease requires surgical therapy.

Nonspecific treatment measures include good hygiene, weight reduction, use of antiseptic detergents, and avoidance of tight-fitting clothes.

  • Acute-stage treatment options
    • Antibiotics: A short course of antibiotics for a period of 2 weeks is usually advisable. The antibiotics used include a combination of erythromycin and metronidazole, minocycline, or clindamycin. Cephalosporins and penicillins can also be used.
    • Intralesional steroids: Intralesional injection of steroids (eg, triamcinolone 5-10 mg diluted with water) causes the early lesions to involute within 12-24 hours.
  • Chronic relapsing–stage treatment options
    • Long-term antibiotics: Long-term administration of erythromycin and tetracycline has been used to treat the chronic stages and is shown to reduce the relapse rate. However, the efficacy of the antibiotics may be lost after long-term use. Efficacy can usually be regained by stopping the drug for a month and restarting it.
    • High-dose systemic steroids (eg, prednisolone 60 mg/d) are useful as adjuvants to antibiotics, and they act by reducing the inflammatory process.
    • Estrogens: Contraceptive pills (eg, 50 mcg ethynyl estradiol) and the combination of estrogens with 100 mg of cyproterone acetate have been used.
    • Retinoids: These have been shown to be effective in the chronic disease. Isotretinoin, at a dose of 1 mg/kg/d, is administered for 4 months. Etretinate, at a dose of 0.5 mg/kg/d for a period of 6 months, is used for patients whose conditions are unresponsive to isotretinoin. Retinoids are teratogenic, and pregnancy is prevented by the use of contraception. Approximately 40% of patients show good response to retinoids.
  • Other therapeutic agents that have been used with limited success include cisplatin, methotrexate, 5-alpha reductase inhibitors, and TNF-alpha inhibitors. Infliximab has been used in patients with Crohn disease and associated hidradenitis suppurativa.
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Surgical Therapy

  • Stage 1 options include incision and drainage, followed by antibiotics.
  • Stage 2 and some stage 3 options include minor procedures.
    • Exteriorization and laying open of tracts and electrocoagulation
    • Excision and primary closure (eg, the Pollock procedure)[9]
  • Stage 3 options include total wide excision and healing with secondary intention or flaps and grafts.
  • Closure of defects is achieved by the following:
    • Z-plasty
    • Skin grafts
      • Thiersch split-thickness grafts
      • Meshed grafts
      • Wolfe full-thickness grafts
    • Flaps[10]
      • Rotation flaps
      • Free flaps
    • Biosynthetics agents, like Biobrane and Integra, have also been used.
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Preoperative Details

  • Be aware of the possibility of associated systemic abnormalities.
  • Perform routine preoperative assessment for surgery and anesthesia, including cardiac, respiratory, and renal assessments.
  • Order antibiotics to treat the acute exacerbations before surgery.
  • Order prophylactic antibiotics before surgery.
  • Warn patients of the likelihood of a large raw area, which will require prolonged postoperative dressings.
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Intraoperative Details

  • Perform a wide excision, with a 1.5-cm margin all around the lesion.
  • Perform intraoperative mapping of the sinus tracts with methyl violet, which reduces recurrence rates.
  • In the genital and perianal area, primary closure is to be avoided, and healing by secondary intention is advocated.
  • Axilla: Total excision with transverse primary closure (ie, the Pollock procedure) is usually possible.
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Postoperative Details

  • Postoperative care
    • Regular and prolonged use of postoperative dressings is necessary to aid secondary healing.
    • Healing can be hastened by the use of silastic foam dressings.
    • The use of Betadine and chlorhexidine dressings and compression has been shown to be of benefit.
  • Postoperative complications
    • Patients can develop general complications, such as pneumonia, deep venous thrombosis (DVT), and infection. Administer routine perioperative DVT and antibiotic prophylaxis.
    • Active physiotherapy, breathing exercises, and early ambulation are encouraged.
    • Postoperative complications specific to the procedure include wound breakdown, hematoma formation, wound infection, and graft rejection and failure.
    • The overall complication rate is 17-20%.
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Follow-up

Patients are monitored in the clinic at regular intervals for at least 6 months before they can be declared to be cured.

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Complications

The complications of long-standing untreated disease include the following:

  • Fistula formation into the urethra, bladder, rectum, or peritoneum has been reported.
  • Sequelae of chronic infection, such as secondary anemia, hypoproteinemia, amyloidosis, and renal disease, can occur in chronic disease.
  • Peripheral and axial arthropathy is possible.
  • Chronic malaise and depression are observed.
  • Scarring of the tissue can lead to lymphatic obstruction and lymphedema of the limbs and arthropathy.
  • Marjolin ulcer (squamous cell carcinoma) has been reported in long-standing chronic disease.
  • Scrotal elephantiasis has been reported.
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Outcome and Prognosis

Locoregional recurrence does arise, and reported rates vary by 30-50%. One series reports a 100% recurrence rate with incision and drainage alone, a 42% recurrence rate with limited excision, and a 27% recurrence rate after radical excision.

Reassessment for several months in the follow-up clinic is required before cure can be assumed with certainty.

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Future and Controversies

The role of radiotherapy in the treatment of the disease is controversial. One series by Frohlich et al in Germany reports complete relief in 38% of patients and improvement in 40% of patients, with 2 patients not showing any response to therapy.[11] No complications were associated with radiotherapy.

Other series have demonstrated that radiotherapy is of no benefit; therefore, the role of radiotherapy as an adjunct is still debated.

Laser therapy has been used for the treatment of hidradenitis suppurativa.

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Contributor Information and Disclosures
Author

Naveen Pokala, MBBS, MS, FRCS  Staff Physician, Department of Surgery, Bronx Lebanon Hospital

Disclosure: Nothing to disclose.

Coauthor(s)

Ravi Pokala Kiran, MBBS, MS, FRCS (Eng), FRCS (Glas)  Staff Physician, Department of General Surgery, St Mary's Hospital

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

David L Morris, MD, PhD, FRACS  Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia

David L Morris, MD, PhD, FRACS is a member of the following medical societies: British Society of Gastroenterology

Disclosure: RFA Medical None Director; MRC Biotec None Director

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA  Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

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Table. The Pathogenesis of Hidradenitis Suppurativa
Keratin comedones



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Occlusion of the apocrine ducts



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Superimposed inflammation and infection



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Abscess formation



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Chronic infection and spread



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Induration and sinus and fistula formation



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