Hidradenitis Suppurativa: Evaluation of Treatment Modalities and Patients’ Satisfaction

Egypt. J. Plast. Reconstr. Surg., Vol. 27, No. 2, July: 231-237, 2003
Hidradenitis Suppurativa:
Evaluation of Treatment Modalities and Patients’ Satisfaction
KHALED M. EL-RIFAIE, M.D.*; TAREK F. EL-WAKIL, M.D.**; AHMAD M. SOBHI, M.D.* and
HISHAM EL-SAKET, M.D.*
The Department of Surgery, Faculty of Medicine* and National Institute of Laser Enhanced Sciences**, Cairo University.
ABSTRACT
and socially handicapped and dressing dependent
[3]. Unfortunately, the end point of the disease
could be the malignant transformation in the
form of squamous cell carcinoma as was reported
in few cases of previous studies [4-5].
Hidradenitis suppurativa (H.S.) disease is a chronic
suppurating disorder of an unknown aetiology. Its management must be individualized according to the affected
regions and the extent of the disease with different success
and recurrence rates. Twenty-one patients with H.S. disease
at different regions and age groups of both sexes were
studied. Five cases were presented as a recurrent disease.
Excision and debridement were done for all the patients.
Some defects were left for granulations and spontaneous
healing while others were covered by either skin grafts or
flaps. The reported results were summarized into short and
long-term results. Short-term results include assessment
of the operative time, patients’ ambulation, postoperative
analgesics, hospitalization period and professional dependency for wound care. Long-term results include social,
cosmetic results, patients’ satisfaction, as well as, the
recurrence rate over a postoperative period of one year
with a single reported recurrence at the axilla of a previously
recurrent case. H.S. patients are of unique characteristics
that suffered for a long time. Wide local excision could be
attributed as the universal treatment modality per se or in
conjunction with other lines for defect’s coverings with
different success and recurrence rates.
The management of H.S. disease must be
individualized to the site and the extent of the
disease. Initial conservative measures with antibiotics, local wound care and limited incision
and drainage can alleviate the acute symptoms
especially at early stages [3]. However, more
radical surgery will likely be necessary in order
to control advanced stages, as well as, to prevent
recurrence. Options include deroofing and marsupialization, local excision, or more extensive
operative excision with primary or secondary
closure, skin grafting, or flap coverage of the
defects. Wide excision will offer the most definitive therapy, with the trade-off being of a high
morbidity [6].
Split-thickness skin grafts in the anal canal
may contract and result into anal stenosis and
should be avoided. Perianal H.S. is often best
managed with local excision alone, with primary
closure for small defects and either deroofing
or healing by secondary intention for larger
defects [7-8]. This could be achieved especially
with the regression of the previously described
diverting colostomy and central hyperalimentation [9-10] for avoidance of faecal contamination
after the advancement at the well-planned preoperative and postoperative bowel regimens [7].
The same policy was suggested for the treatment
of H.S. of the groin [11], while others suggested
a new surgical treatment for chronic gluteal H.S.
with the reused or recycled skin graft from the
resected skin itself [2].
INTRODUCTION
Hidradenitis suppurativa (H.S.) disease is a
chronic socially debilitating disorder of unknown
etiology. Physicians usually under-estimate the
extent of the patient disability especially perineal
and perianal H.S. [1]. At earlier stages of the
disease, responding localized lesions are present.
Quiescence is inconsistency achieved with the
good personal hygiene and by avoidance of
depilatories, shaving, irritating cloths and deodorants [2]. Later on, chronic disease developed
when multiple abscesses, inflammatory induration, ulcerative sinus tracts and mal-odorous
discharge were present. At this stage only, the
patient seeks the surgical advice when the condition is miserable. The patient became physically
231
232
Vol. 27, No. 2 / Hidradenitis Suppurativa
Moreover, there is a controversy about how
to cover the defect after excision of axillary H.S.
disease. Some authors recommended covering
the defect by the use of fasciocutaneous flaps
[1,12-14], while others recommended scapular
island or parascapular flaps [14,15]. However,
many authors reported better results of splitthickness grafting for the coverage than primary
suturing, flaps, or even left for secondary intention [16,17] especially with the aid of negative
pressure dressing [18].
Recently, carbon dioxide (CO2) laser (wavelength of 10600 nm) was introduced for the local
excision of chronic H.S. disease [19-20] which
could be optionally applied through a scannerassisted [21]. This new innovative modality for
excision could facilitate the identification of
coagulase-negative staphylococci, which are
mostly present and cultured from the deeper
planes of chronic H.S. disease [22].
Collectively, although a number of different
reconstructive techniques have been described
for the treatment of H.S. disease, none of them
could be described as the treatment of choice
and all of these treatment modalities can leave
unsightly scars. This motivates us for the initiation of the present study to investigate the advantages and disadvantages of the different
modalities for the treatment of H.S. at different
locations with their implication for patients’
satisfaction.
PATIENTS AND METHODS
Twenty-one patients with H.S. disease involving the axilla, perineal, perianal, groin,
gluteal and scrotal regions were studied. Five
patients presented with recurrent H.S. There
were two patients with recurrent H.S. disease at
the axilla, while recurrent H.S. disease at gluteal,
groin and perineal regions were present in one
patient at each site. Moreover, two patients with
axillary H.S. presented with bilateral lesions.
All patients were treated from 1999-2001. They
were reviewed in Table (1). There were 13 males
(61.91%) and 8 females (38.09%). Their ages
were ranged from 36-72 years with a mean of
57.48±10.51 years. Involved skin and apocrine
tissue were excised to a clean, non-scarred area
of subcutaneous tissue. In few selected cases,
excision of the involved skin was done by the
aid of CO2 laser (wavelength 10600 nm), DEKKA, Italy, at a power of 15W, pulsed at a pulse
duration of 0.2 sec. The nearby fistulous tracts
were deroofed to provide an adequate drainage
and granulation tissue was excised and curetted.
The average excised surface area was 320 cm2.
After excision, wounds were too large for
consideration of primary closure. There are
different types for defect coverage, which are
basically depended upon the site of the defect.
In patients presented with groin H.S., skin coverage after excision was achieved by external
oblique rotation fasciocutaneous in all the 5
cases (Fig. 1:a and b). In the case with gluteal
H.S., coverage with split-thickness graft was
done. In the ten cases with perineal and perianal
H.S., the defects were left for secondary intention
(Fig. 2). In five cases with axillary H.S., parascapular flaps were used at 5 sites and splitthickness grafts at 2 sites (Fig. 2: a, b and c).
Broad-spectrum antibiotic coverage was generally provided with the induction of general
anaesthesia to control the intraoperative bacteremia. Postoperative specific antibiotic coverage
according to cultured organisms was provided.
Operative wounds were dressed initially and
changed the morning after surgery. Thereafter,
dressings were changed four times daily. The
patients were encouraged to ambulate as tolerated
as early as possible. The patients were discharged
when analgesic requirements were minimal and
when a reliable outpatient wound care could be
ensured. Patients were followed on an outpatient
basis until healing was complete. They were
evaluated on a weekly basis and then much less
frequently, depending on their needs and desires
for up to a year after surgery. Patients were
interviewed according to a standardized questionnaire to assess the short and long-term results.
The results can be evaluated as short and
long-term results. The short-term results include;
assessment of the operative time, patients’ ambulation, postoperative analgesics, duration of
hospitalization and the hospital-dependency for
wound care. However, the long-term results
include; social results in the form of patients’
return to work, patients’ satisfaction and the final
cosmetic results of the scar as well as the recurrence of the H.S. disease or any other complications if present. Recurrence may be either locoregional that appear at the surgical site, or de
novo suppurating lesions that appear at sites
more than 5 cm away from the surgical site.
Egypt, J. Plast. Reconstr. Surg., July 2003
233
Fig. (3-A): A
preoperative
photograph
of a case
with axillary
H.S. disease.
Fig. (1-A): A preoperative photograph of a case with groin
H.S. disease.
Fig. (3-B): The
operative
defect after
excision.
Fig. (1-B): Postoperative photograph of external oblique
fasciocutaneous flap.
Fig. (3-C): Postoperative photograph of a
healed split
thickness skin
graft.
Fig. (2): A preoperative photograph of a case with perianal
H.S. disease.
234
Vol. 27, No. 2 / Hidradenitis Suppurativa
Table (1): Review of the patients’ data.
Patient
Age
Sex
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
52
66
72
36
68
59
50
62
47
39
55
70
60
51
51
66
70
62
45
57
69
Female
Male
Male
Male
Female
Male
Female
Female
Male
Female
Male
Male
Female
Male
Male
Male
Male
Female
Male
Female
Male
RESULTS
The initial surgical intervention is usually in
the form of a debridement. The operative time
spent in most instances was less than one hour,
while it was longer when flaps were designed
to cover the wounds’ defects. The majority of
the operative time was spent for careful debridement and curettage, as well as, for haemostasis
that is why CO2 laser stripping could be of value.
It was found that the patients’ ambulation
from beds was achieved from the morning after
surgery, which was initially with assistance. Two
of our patients required no postoperative analgesics. Most patients reported a major reduction
of the local discomfort as compared to the preoperative state. However, the condition is usually
aggravated during and after dressings. By the
3rd-4th postoperative day, all patients had minimal
analgesic requirements with satisfactory pain
control.
The period of hospitalization ranged from 2
days to 2 weeks. The prolonged hospital staying
was due to complicated medical problems like
controlling of diabetes mellitus or systemic
hypertension. The longer hospitalizations were
Disease distribution
Groin
Perineum
Perineum and scrotum
Axilla
Groin (Recurrent)
Perineum
Groin
Axilla
Axillae (Bilateral, recurrent)
Groin
Gluteal (Recurrent)
Perineum
Perineum
Perineum
Axilla (Recurrent)
Perineum (Recurrent)
Groin
Perineum
Axillae (Bilateral)
Perineum
Perineum
Healing time
3 months
5 months
6 months
4 months
4 months
5 months
5 months
3 months
6 months
5 months
4 months
5 months
5 months
3 months
4 months
6 months
5 months
4 months
3 months
3 months
4 months
uniformly with older patients to allow closer
wound observation especially for those with
flaps and split-thickness grafts for covering and
dressings especially for those cases who were
left to cover by secondary intention until adequate
and uncomplicated home-based care could be
achieved.
Regarding the wound care, a clean sterile
technique, as well as, the use of minimal expenditures for gauze sponges were encouraged. The
majority of patients were not hospital-dependant
for regular dressing and only continue a smoothly
home-based care. Only three patients required
assistance for dressing care and were easily
managed by spouse and/or family members.
Complete healing required from 3 to 6 months,
which depends on the extent of the initial disease
and the debridement area.
All the patients were followed postoperatively
for 6-12 months to ensure, not only the complete
cure of the disease, but also to assess the recurrence of an active disease. The duration of the
healing was found ranging from 3 to 6 months
(mean of 4.38±1.02 months). Follow-up examinations were completed with a questionnaire at
Egypt, J. Plast. Reconstr. Surg., July 2003
the time of the hospital discharge or on the later
recall to the outpatient clinics for good assessment of the patient’s satisfaction. There was
only one patient reported unsatisfactory results
as was denoted by a starting recurrent axillary
H.S. disease at the margins of the area covered
by a split-thickness graft. This was found to be
recurrent for the second time, but only on one
side. In this case, however, the reported disease
was mild as compared to the original state of
the disease. Recovery was achieved with minor
excision of additional skin and apocrine glands
and continued for dressings aiming to cover the
defect by secondary intention.
Seven patients had been unemployed due to
the severity of their disease. Five of those patients
were able to assume gainful employment about
3 months after their hospital discharge. Previously employed patients were generally returned
to work about 3 weeks after hospital discharge.
No patient reported inconvenience with the
dressing care during the healing period when
compared with his/her preoperative dressing
requirements.
The long-term results entail that all patients
were satisfied about the final appearance of their
wounds after complete healing. Two patients
expressed concern for scar hypertrophy at the
12th postoperative month evaluation. Additionally, one patient expressed minor concern for
apparent scar spreading where healing occurred,
in part, through epithelization. No scars were
reported to be painful or to be irritated by the
overlying cloths. No limitation of the daily
activities was demonstrated and in fact, all patients described a considerable improvement
over the preoperative state. Many patients had
become active in various athletic activities without any restriction.
DISCUSSION
The key-point of the success of the surgical
approaches and the patients’ satisfaction relates
to the recognition of the unique characteristics
of the patient population with H.S. disease.
Patients with chronic H.S. have generally suffered with their disease for many years before
any surgical intervention [3,17]. They are quite
familiar with the dressing techniques and therefore require little reinforcement to maintain
themselves during the prolonged interval of
healing. Their pain threshold has been, through
235
the chronicity of the discomfort, heightened to
a point where they tolerate the open wound
technique with very minimal need for analgesia.
Their entire lifestyle has for so long focussed
about showers, baths and dressing changes.
The present study agrees with the previous
investigation that appreciates a definite sense of
well being attributed to early mobilization of
the patient [6]. We have recognized an extreme
patient satisfaction attributed to their selfparticipation in their wound care. From these
key points and before decision-making was
taken, many aspects must be considered. This
includes; first: the region affected, second: to
start with conservative treatment or to excise
the affected skin, third: to use either surgical or
laser-assisted excision, fourth: to cover or to
leave the defect for granulation and finally: what
type of coverage if it was decided.
Initiative conservative measures could be
started with [3], however, in the present study,
we preferred to start with local excision taking
into consideration the long time spent before
requesting the surgical advice especially when
the history of recurrence was present. Moreover,
CO2 laser assisted excision was applied in few
selected cases at the present study. It could offer
a rapid, efficient and economical technique,
which could be applied alone as a simple treatment modality in some early lesions [19-21] .
Moreover, CO2 laser excision could give a hand
for better diagnosis of coagulase negative staphylococci at the deeper planes of H.S. diseased
area for selective postoperative antibiotic coverage [22].
Excision and debridement of the affected
skin and apocrine glands were applied in the
present study as the only line of treatment for
H.S. disease affecting the perianal and perineal
regions when healing with secondary intention
is the end point of the treatment. This is true as
anal stenosis could be complicating after splitthickness skin graft covering [7,8] and the concepts for diverting colostomy became obsolete
especially after the introduction of well-planned
bowel protocols [9]. This modality of treatment
has different advantages namely; easier postoperative care, full and early ambulation, no donor
sites, no losses of skin grafts, short-term hospitalization and early return to work [11]. In H.S.
disease of the gluteal region, on the contrary,
the split-thickness graft could be considered the
236
preferred line of treatment especially with the
introduction of the recycled skin grafting from
the resected skin without the need for a donor
area [2].
The true dilemma of the proper line of treatment was for the coverage of the defects after
excision of H.S. disease at the groin and the
axillae. In H.S. disease at the groin, some authors
suggested to keep the defect opened for secondary intention [11] while others preferred closure
by flap coverage [10]. In the present study, we
preferred coverage for cases with H.S. disease
at the groin by flaps. It could offer earlier mobilization, lesser hospitalization, lesser dependency
for dressings and better healing for patients’
satisfaction. In H.S. disease at the axilla, we
preferred to cover the defects by both splitthickness grafts and flaps taking into consideration the size of the defect as the previous studies
did not decide the ideal way for covering of
those defects with different reported recurrence
rates [1,13,16,18]. In the present study, the only
case with recurrence was at the axilla, precisely
at the margin of the excised skin. This could be
attributed to a defect of the proper wide excision
of the affected skin and apocrine glands rather
than a defect of the covering technique, especially, when the recurrence was for the second
time.
At an earlier stage of the present study, we
were not appreciated the patients’ characteristics
and premature impatience with the slow healing.
So, prompted reappraisal of our treatment program to selectively offer skin grafting to several
patients to expedite healing was done. The
present study stresses about the idea of the
potential source of dissatisfaction for those
patients regardless of the treatment modality. In
as much as it hardly seems advisable to extend
the operative resection beyond the actively diseased apocrine tissue, the potential for further
disease in the previously uninvolved areas is
quite real. Patients need to be clearly informed
of this possibility so as not consider the original
operation a failure. The small percentage at the
present study with such a problem represents
the severity of the disease on the initial presentation and the fact that nearly complete apocrine
gland excision occurred with excision of all
active diseased skin.
Conclusion:
H.S. disease is a chronic long-lasting prob-
Vol. 27, No. 2 / Hidradenitis Suppurativa
lem. The debate about its ideal line of treatment
is a superimposed problem, taking into consideration the affected regions. Simple wide excision
could be attributed as the universal line of treatment alone or in conjunction with different ways
to cover the defects. The optimum goal of treatment is to control the disease with good functional and cosmetically acceptable properties,
as well as, the least incidence of disease recurrence. Patients’ satisfaction is directly attributed
to the previous goals and in addition to the early
ambulation, early discharge, home-based wound
care until healing is complete to minimize the
operative and hospitalization costs in a time of
escalating the medical expenditures and the
potential governmental intervention.
REFERENCES
1- Geh J.L. and Niranjan N.S.: Perforator-based fasciocutaneous island flaps for the reconstruction of axillary
defects following excision of hidradenitis suppurativa.
Br. J. Plast. Surg., 55 (2): 124-128, 2002.
2- Kuo H.W. and Ohara K.: Surgical treatment of chronic
gluteal hidradenitis suppurativa: reused skin graft
technique. Dermatol. Surg., 29 (2): 173-178, 2003.
3- Mitchell K.M. and Beck D.E.: Hidradenitis suppurativa.
Surg. Clin. North Am., 82 (6): 1187-1197, 2002.
4- Manolitsas T., Blankin S., Jaworski R. and Wain G.:
Vulval squamous cell carcinoma arising in chronic
hidradenitis suppurativa. Gynecol. Oncol., 75 (2): 285288, 1999.
5- Elwood E.T. and Bolitho D.G.: Negative-pressure
dressings in the treatment of hidradenitis suppurativa.
Ann. Plast. Surg., 46 (1): 49-51, 2001.
6- Tanaka A., Hatoko M., Tada H., Kuwahara M., Mashiba
K. and Yurugi S.: Experience with surgical treatment
of hidraenitis suppurativa. Ann. Plast. Surg., 47 (6):
636-642, 2001.
7- Ramasastry S.S., Conklin W.T., Granick M.S. and
Futrell J.W.: Surgical management of massive perianal
hidradenitis suppurativa. Ann. Plast. Surg., 15 (3):
218-223, 1985.
8- Rubin R.J. and Chinn B.T.: Perianal hidradenitis
suppurativa. Surg. Clin. North Am., 74 (6): 1317-1325,
1994.
9- Tofield J.J.: Intravenous hyperalimentation: A valuable
aid for perianal skin grafting. Br. J. Plast. Surg., 30:
154-158, 1977.
10- Billet A., Stueber K. and Vaughan L.: Hidradenitis
suppurativa of unusual severity. Ann. Plast. Surg., 10:
231-236, 1983.
11- Ariyan S. and Krizek T.J.: Hidradenitis suppurativa of
the groin, treated by excision and spontaneous healing.
Plast. Reconstr. Surg., 58 (1): 44-47, 1976.
Egypt, J. Plast. Reconstr. Surg., July 2003
12- Elliot D., Kangesu L., Bainbridge C., Venkataramakrishnan V.: Reconstruction of the axilla with a posterior
arm fasciocutaneous flap. Br. J. Plast. Surg., 45 (2):
101-104, 1992.
13- Soldin M.G., Tulley P., Kaplan H., Hudson D.A. and
Grobbelaar A.O.: Chronic axillary hidradenitis: the
efficacy of wide excision and flap coverage. Br. J.
Plast. Surg., 53 (5): 434-436, 2000.
14- Schwabegger A.H., Herczeg E. and Piza H.: The lateral
thoracic fasiocutaneous island flap for the treatment
of recurrent hidradenitis axillaris suppurativa and other
axillary skin defects. Br. J. Plast. Surg., 53 (8): 676678, 2000.
15- Amarante J., Reis J., Santa Comba A. and Malheiro
E.: A new approach in axillary hidradenitis treatment:
the scapular island flap. Aesthetic Plast. Surg., 20 (5):
443-446, 1996.
16- Morgan W.P., Harding K.G. and Hughes L.E.: A comparison of skin grafting and healing by granulation,
following axillary excision for hidradenitis suppurativa.
Ann. R. Coll Surg. Engl., 65 (4): 235-236, 1983.
17- Watson J.D.: Hidradenitis suppurativa: a clinical review.
237
Br. J. Plast. Surg., 38 (4): 567-569, 1985.
18- Hynes P.J., Earley M.J. and Lawlor D.: Split-thickness
skin grafts and negative-pressure dressings in the
treatment of axillary hidradenitis suppurativa. Br. J.
Plast. Surg., 55 (6): 507-509, 2002.
19- Lapins J., Marcusson J.A. and Emtestam L.: Surgical
treatment of chronic hidradenitis suppurativa: CO2
laser stripping-secondary intention technique. Br. J.
Dermatol., 131 (4): 551-556, 1994.
20- Finley E.M. and Ratz J.L.: Treatment of hidradenitis
suppurativa with carbon dioxide laser excision and
second-intention healing. J. Am. Acad. Dermatol., 34
(3): 465-469, 1996.
21- Lapins J., Sartorius K. and Emtestam L.: Scannerassisted carbon dioxide laser surgery: a retrospective
follow-up study of patients with hidradenitis suppurativa. J. Am. Acad. Dermatol., 47 (2): 280-285, 2002.
22- Lapins J., Jarstrand C. and Emtestam L.: Coagulasenegative staphylococci are the most common bacteria
found in cultures from the deep portions of hidradenitis
suppurativa lesions, as obtained by carbon dioxide
laser surgery. Br. J. Dermatol., 140 (1): 90-95, 1999.