Surgical treatment of perianal and perineal hidradenitis suppurativa

Surgical Treatment of Perianal and Perineal
Hidradenitis Suppurativa*
.JOSEPH P. THORNTON, M.D., HERAND ABCARIAN, M.D.
HIDRADENITIS SUPPURATIVA involves the a p o c r i n e
glands and is characterized by chronic r e c u r r e n t suppurative lesions in the axilla, groin, external genitalia
and perianal regions. Other, less c o m m o n , sites o f
o c c u r r e n c e are the n a p e o f the neck, areola o f the
breasts, s u b m a m m a r y fold, a n d periumbilical regio n.
Hidradenitis s u p p u r a t i v a is not strictly g e r m a n e to
colonic and rectal surgery; cases have been r e p o r t e d
by p l a s t i c s u r g e o n s , i n t e r n i s t s , d e r m a t o l o g i s t s ,
gynecologists, urologists, and general surgeons. In
this paper, a large series o f patients with perianal and
perineal hidradenitis s u p p u r a t i v a is p r e s e n t e d in an
a t t e m p t to clarify conflicting i n f o r m a t i o n a n d to establish principles o f surgical treatment.
Materials and M e t h o d s
T h e r e c o r d s o f 104 patients with p e r i a n a l a n d
perineal hidradenitis s u p p u r a t i v a who were treated
by the Colon a n d Rectal S u r g e r y Service at Cook
County Hospital f r o m 1972 to 1977 were studied retrospectively. T h e r e were 71 m e n a n d 33 w o m e n in
this g r o u p , a n d all hut f o u r patients w e r e black.
Seventy-eight per cent o f the patients were less than
31 years of age. Conversely, only 13 per cent of the
patients were m o r e than 40 years o f age (Table 1).
A m o n g the 104 patients a d m i t t e d with perineal and
perianal hidradenitis suppurativa, 59 (57 per cent) reported previous similar episodes. T h e sites of prior occurr e n c e were the p e r i n e u m or perianal region; in 74
per cent, the groin, 14 per cent, the axilla, 12 p e r cent
(Table 2). Only 33 p e r cent of patients who h a d rec u r r e n t disease h a d had any type o f p r i o r t r e a t m e n t ,
which had consisted o f incision a n d d r a i n a g e with
local or regional anesthesia in nearly every case. T h e
* Read at the meeting of the American Society of Colon and
Rectal Surgeons, San Diego, California, June 11 to 15, 1978.
Address reprint requests to Dr. Abcarian: Section of Colon and
Rectal Surgery, Cook County' Hospital, 1825 W. Harrison Street,
Chicago, Illinois 60612.
From the Section of Colorz and Rectal Surge U,
Cook County Hospital, and the
Department of Surgery, University of Illinois
Abraham Lincoln School of Medicine,
Chicago, Illinois
TABLE 1. Age Distribution of 104 Patients with
Perianal and PeT~nealHidradenitis Suppurativa
Patients
Age
(Years)
Number
15-20
21-30
31-40
41-50
> 50
26
55
10
6
7
25
53
9
6
7
104
100.0
TOTAL
Per Cent
TABLE 2. Prior Episodes of Hidradenitis Supp~zrativa
in 59 Patients with Recurrent Disease
Patients
Location
Number
Per Cent
Perianal
Groin
Axilla
44
8
7
74
14
12
59
100
TOTAL
r e m a i n i n g patients r e p o r t e d s p o n t a n e o u s d r a i n a g e o f
the involved area. T w o or m o r e sites o f perianal inv o l v e m e n t were f o u n d in 17 per cent of the patients.
Associated diseases were relatively u n c o m m o n . Diabetes mellitus was seen in three patients. In a 51-
0012-3706/78/1100/0573/$00.75 9 American Society of Colon and Rectal Surgeons
573
574
THORNTON
Duratio'm of Symptoms in 104
Patients with Hidradenitis Suppurativa
TABLe 3.
Patients
Days
Number
0-5
6-10
> 10
TOTAL
Col. & Rect.
Nov.-Dec. 1978
Dis.
AND A B C A R I A N
Per Cent
62
18
24
60
17
23
104
100
are r e m o v e d on the first postoperative day', the patient is ambulated, and sitz baths at least f o u r times a
day are started. T h e w o u n d is covered with gauze
sponges after each bath. Analgesia is m a i n t a i n e d with
orally administered medications when necessary. T h e
patient is discharged as soon as he is afebrile, comfortable, and able to care for the wound. T h e patient
is then followed in the o u t p a t i e n t d e p a r t m e n t on a
biweekly basis until c o m p l e t e w o u n d h e a l i n g is
achieved (Fig. 1C).
Results
year-old woman, the excised specimen was f o u n d to
contain invasive squamous-cell carcinoma, necessitating a b d o m i n o p e r i n e a l resection. A few o t h e r interc u r r e n t diseases were f o u n d on an incidental basis.
Durations o f symptoms are summarized in Table 3.
A history o f five days or less was given by 60 per cent
o f the g r o u p , and a n o t h e r 17 per cent had had
symptoms for seven to ten days.
Surgical Technique
All patients with hidradenitis suppurativa o f the
p e r i n e u m or perianal region admitted to the Colon
and Rectal Surgery Service at Cook County Hospital
are treated by i m m e d i a t e drainage o f the involved
area with local anesthesia. A sample o f the drained
pus is sent for culture and antibiotic sensitivity testing
(Table 4). A brief preoperative work-up is completed,
and the following day a definitive o p e r a t i o n is performed, using caudal or spinal anesthesia, with the
patient in the p r o n e jackknife position (Fig. IA). T h e
operative p r o c e d u r e for all patients consists o f wide
excision o f the involved area down to normal fat or
fascia, using electrocautery (Fig. 1By. W o u n d s are
packed with i o d o f o r m gauze and an occlusive dressing is applied. Diverting colostomy or skin grafts are
not utilized routinely. T h e dressing and gauze pack
TABLE 4. Results of Wound Culture in Cases of
Patients with Hidradenitis Suppurativa
Results
No growth (n = 50)
Positive growth (n = 54)
Staphylococcus epidermidis
Eseherichia coli
Alpha streptococcus
Others (including mixed
flora)
Per Cent
48
52
44
t9
15
22
T h e average hospital stay was 7.2 days. Table 5
shows that 65 per cent o f the patients were hospitalized for five days or less and 80 per cent of the
patients were discharged by the tenth postoperative
day. Patients m o r e than 40 years old, however, had an
average hospital stay' o f 18.7 days.
T h e size o f the w o u n d as r e c o r d e d on the pathology r e p o r t was arbitrarily assigned to one o f three
groups: small (2 x 2 cm), medium-sized (2-5 x 2 - 5
cm) or large (more than 5 cm in any dimension).
Healing time was c o m p a r e d with size o f the w o u n d at
operation. Average healing times r a n g e d from 3.5
weeks for small wounds to m o r e than seven weeks for
large ones (Table 6). T h e r e was no d e a t h in this
g r o u p o f patients, and only' f o u r patients were reoperated on for r e c u r r e n c e o f this condition in the fiveyear period o f this study'.
Discussion
Hidradenitis suppurativa is caused by inflammation o f the apocrine glands, hence the p r e d o m i n a n t
incidence in the perianal, perineal, axillary and inguinal regions. T h e disease favors y o u n g adults. In
the present series, the ratio o f m e n to w o m e n was
2:1.9 However, in a few series there have been higher
incidences a m o n g women. T h e apocrine glands function after puberty, l'a and the incidence o f this disease
increases in the third and f o u r t h decades o f life 9 (78
per cent of patients in o u r series were less than 30
years o f age).
T h e disease can be either acute or chronic. In the
acute stage, few deep-seated cutaneous nodules occur
in an area o f cellulitis. T h e s e nodules s u p p u r a t e and
c o n n e c t via s u b c u t a n e o u s i n f l a m m a t o r y c o r d s .
Should the disease go u n t r e a t e d or t r e a t m e n t be limited to incision and drainage, r e p e a t e d exacerbation is
inevitable and will result in n u m e r o u s abscesses and
d r a i n i n g sinuses in a thick, c o n t r a c t e d , fibrotic
cutaneous background, a,9 In the present series more
Volume 2I
Number 8
SURGERY FOR HIDRADENITIS SUPPURATIVA
FIG. 1. A (above, left). Bilateral perianal hidradenitis suppurativa in a 35-year-old black man.
B (above, right). Appearance of the wound immediately postoperatively, demonstrating extensive excision of all affected tissue
down to normal subcutaneous fat. Diverting colostomy was not
used.
C (righO. Complete wound healing, achieved in eight weeks.
575
576
THORNTON AND ABCARIAN
Hospital Stays of 104 Patients
with Hidradenitis Suppurativa
TABLE 5.
Length of
Stay
(Days)
0-5
6-10
11-20
>20
TOTAL
Patients
Number
Per Cent
68
16
12
8
65
15
12
8
104
t00
than half o f the patients had r e c u r r e n t episodes o f
hidradenitis and o f these patients, 74 per cent had
r e c u r r e n t infections in the perianal a r e a .
Various modalities o f t h e r a p y have been recomm e n d e d for hidradenitis suppurativa. Verneuil n is
credited with r e c o m m e n d i n g incision and drainage o f
the fluctuant area as s u p p u r a t i o n is frequently the
complaint for which the patient seeks treatment. Even
now Verneuil's m e t h o d is the most c o m m o n , alt h o u g h some have r e s o r t e d to t r e a t m e n t t h r o u g h
diet, heat, ultraviolet irradiation, vaccination, steroids
and antibiotics, all with p o o r resuhs. 9' 10.12
G o o d success with surgical excision o f the affected
areas was r e p o r t e d by Lane r in 1933. Since that report, others have advocated early, aggressive surgical
excision o f all affected areas. ''a'9,10 Following surgical
excision, the o p e n w o u n d can be treated in three
ways. 1) p r i m a r y closure with o r without skin flaps; 2)
split-thickness skin grafting; 3) leaving the w o u n d
o p e n and allowing it to close by secondary granulation and epithelialization.
P r i m a r y c l o s u r e is usually suitable f o r a small
w o u n d located in a relatively clean area, i.e., the axilla.
Simple closure, Z-plasty and o t h e r flap techniques
have been described, s,9 A few successful cases o f prim a r y c l o s u r e a f t e r excision o f h i d r a d e n i t i s suppurativa o f the groin o r p e r i n e u m have b e e n reported. 1'2'1~ However, most investigators agree that
because o f the c o n t a m i n a t e d e n v i r o n m e n t , o p e n
perineal w o u n d s s h o u l d not be closed primarily. 9
Ching and Stahlgren r e p o r t e d a few cases o f splitthickness skin grafting with good results, but Knaysi et
al. 6 had poor results when this technique was used in
the groin and perineal areas. Conway et al. 3 advocated
split-thickness skin grafting o f the o p e n w o u n d to
p r e v e n t scar formation. T h i s appears to be m o r e app r o p r i a t e for the axilla. T h e results o f o u r study
Fro. 2. A (/eft). Hidmdenitis suppurativa in a 63-year-oldblack woman with extensiveperianal, perineal, vulvar and inguinal involvement.
(B) (right). Operative photograph, showing the extensive excision of all diseased areas. A diverting colostomy was made in this case.
Volume 21
Number 8
577
SURGERY FOR HIDRADENITIS SUPPURATIVA
strongly support those of Letterman and Schurter, 8
V i c k e r s v' a n d M a s s o n 9 in t h a t r a p i d h e a l i n g a n d exc e l l e n t r e s u l t s can b e a c h i e v e d by p a c k i n g t h e p e r i n e a l
w o u n d s o p e n to h e a l with s e c o n d a r y g r a n u l a t i o n . I n
our series the contractures of the wounds were minireal a n d t h e p e r i n e u m was p l i a b l e a n d n o n t e n d e r .
T h e a v e r a g e h o s p i t a l stay o f s e v e n d a y s in o u r s e r i e s
also c o m p a r e s f a v o r a b l y with t h e m e a n 12 d a y s rep o r t e d by V i c k e r s ? 2
R o u t i n e a n t i b i o t i c s a n d skin g r a f t i n g w e r e n o t u s e d
in o u r series. I n t e n o f 13 p a t i e n t s (76) m o r e t h a n 40
y e a r s old, h i d r a d e n i t i s s u p p u r a t i v a was q u i t e e x t e n sive, a n d t h e r e s u h a n t w o u n d s w e r e v e r y l a r g e (Fig.
2A ). H o w e v e r , c o n t r a r y to C h i n g a n d S t a h l g r e n ' s reco m m e n d a t i o n f o r r o u t i n e colostomy,'-' d i v e r t i n g colost o m y was u s e d in only' o n e p a t i e n t , a n e l d e r l y , o b e s e
w o m a n with l a r g e a r e a s o f p e r i n e a l e x c i s i o n , w h o was
e x p e c t e d to b e d i f f i c u l t to a m b u l a t e p o s t o p e r a t i v e l y
f o r f r e q u e n t sitz b a t h s (Fig. 2B). All o f t h e o t h e r p a t i e n t s h a d n o r m a l , i n t a c t a n a l c a n a l s a n d w e r e easy to
a m b u l a t e ; t h e y w e r e t r e a t e d w i t h o u t a d i v e r t i n g colostomy.
F i n a l l y , o n e case o f i n v a s i v e s q u a m o u s - c e l l c a r c i n o m a was s e e n i n a p a t i e n t w h o h a d h a d h i d r a d e n i t i s s u p p u r a t i v a for m o r e t h a n 20 years. A similar
case has be~n reported by Donsky and Mendelson, 4 a n d J a c k m a n , s in r e v i e w i n g 125 cases o f c h r o n i c
hidradenitis suppurativa found four patients with
s q u a m o u s - c e l l c a r c i n o m a f o r a n i n c i d e n c e o f 3.2 p e r
cent. T h a t all p a t i e n t s with i n v a s i v e s q u a m o u s - c e l l
carcinoma had had hidradenitis suppurativa for more
t h a n 20 y e a r s stresses t h e n e e d f o r e a r l y excision.
Conclusion
One hundred four patients who had perianal and
perineal hidradenitis suppurativa were treated with
early, extensive and complete surgical excision; longt e r m r e s u l t s w e r e e x c e l l e n t , h o s p i t a l stays w e r e s h o r t ,
a n d t h e r e c u r r e n c e r a t e was low. All w o u n d s w e r e
a l l o w e d to h e a l by s e c o n d a r y g r a n u l a t i o n . N o a n t i b i otics w e r e a d m i n i s t e r e d , t h e r e was n o s p l i t - t h i c k n e s s
TABLE 6. Relationship of Wound Size
to Wound Healing Time
Size
Incidence
(Per Cent)
Healing Time
(Weeks)
20
58
22
3.5
5
7
Small (2 x 2 cm)
Medium (2-5 x 2-5 cm)
Large (more than 5 cm
in any dimension)
skin g r a f t i n g , a n d a d i v e r t i n g c o l o s t o m y was u s e d in
only one patient.
References
1. Chalfant WP, Nance FC: Hidradenitis suppurativa of the
perineum: Treatment by radical excision. Am Surg 36:331,
1970
2. Ching CC, Stahlgren LH: Clinical review of hidradenitis suppurativa: Management of cases with severe perianal involvement. Dis Colon Rectum 8: 349, 1965
3. Conway H, Stark RB, Climo S, et al: The surgical treatment of
chronic hidradenitis suppurativa. Surg Gynecol Obstet
95: 455, 1952
4. Donsky HJ, Mendelson CG: Squamous cell carcinoma as a
complication of hidradenitis suppurativa. Arch Dermatol
90: 488, 1964
5. Jackman RJ: Hidradenitis suppurativa: Diagnosis and surgical
management of perianal manifestations. Proc R Soc Med
Suppl 52: 110, 1959
6. Knaysi GA Jr, Cosman F, Crickelair GF: Hidradenitis suppurativa. JAMA 203: 19, 1968
7. Lane JE: Hidrosadenitis axillaris of Verneuil. Arch Dermatol
28: 609, 1933
8. Letterman G, Schurter M: Surgical treatment of hyperhidrosis
and chronic hidradenitis suppurativa. J Invest Dermatol
63:174, 1974
9. Masson JK: Surgical treatment for hidradenitis suppurativa.
Surg Clin North Am 49:1043 (Oct) 1969
10. Shaughnessy DM, Greminger RR, Margolis IB, et al: Hidradenitis suppurativa: A plea for early operative treatment.
JAMA 222: 320, 1972
11. Verneuil A: De l'hiderosadenite phtegmoneuse et des abces
sudoripares. Arch Gen Med Paris 4: 537, 1864
12. Vickers MA Jr: Operative management of chronic hidradenitis
suppurativa of the scrotum and perineum. J Urol 114:414,
1975