Hidradenitis suppurativa (HS, synonym acne inversa) is a cicatrizing and frequently persistent inflammatory disorder of the sebaceous follicles and terminal hair follicles of apocrine-gland-bearing areas in the adult [12, 31]. The condition may remain relatively mild but nevertheless distressing , ranging from a few but recalcitrant suppurating lesions to an advanced widespread and disabling disease lasting for years or decades. Possible consequences of longstanding, recurrent disease are multiple surgery and considerable social burden caused by chronic infection, with purulent discharge, odor, and pain . In addition, there is a risk of developing a squamous cell carcinoma [9, 36, 40, 73],
Fig. 22.1 a-c. A 30-year-old man before (a), directly after (b) scanner-assisted carbon dioxide laser vaporization of hidradenitis suppurativa of the axilla, the lesions delin eated by ink, and 6 weeks later (c), without closure of the defect, i.e., only secondary healing
Fig. 22.1 a-c. A 30-year-old man before (a), directly after (b) scanner-assisted carbon dioxide laser vaporization of hidradenitis suppurativa of the axilla, the lesions delin eated by ink, and 6 weeks later (c), without closure of the defect, i.e., only secondary healing especially in the perianal region . The etiology of HS is obscure.
Hyperkeratosis of the follicular infundibu-lum forming comedo-like impactions occludes the pilosebaceous apparatus [5, 34, 69]. This is followed by rupture of the follicular canal and the spilling of foreign-body material into connective tissue. The dumping of foreign material such as corneocytes, bacteria, sebaceous matter, and hairs into the connective tissues excites an inflammatory infiltrate. The infiltrate consists initially of granulocytes, followed by mononu-clear cells, and forms a foreign-body granuloma. Epithelial strands are formed and evolve to keratin-producing sinuses lined with squamous epithelium, and fistulas and secondary comedones are typical features [5, 34, 69]. The tissue reaction is complicated by extensive inflammation and enhanced by secondary bacterial colonization and secondary bacterial infection [28, 39, 48]. This chronic inflammatory process produces richly deforming and contracting fibrotic scar tissue with subsequent functional defects [5, 34, 37, 72].
Many therapies have been tested, often frus-tratingly with limited or temporary results. In refractory cases surgery is essential and recommended as early as possible.
In the classic Hurley clinical grading system , Stage I consists of one or more abscesses with no sinus tract and cicatrization and Stage II consists of one or more widely separated recurrent abscesses, with a tract and scarring. The most severe cases (Stage III) are described as having multiple interconnected tracts and abscesses throughout the entire affected area. The Hurley grading system is very useful for overall classification of cases and may form the basis for selection of appropriate treatment in a selected anatomical region. Most patients seen in Departments of Dermatology and many of those with HS have a milder course, usually Hurley Stage II. Hurley Stage II is the commonest type of HS . Milder cases may be manageable with medical therapy; Hurley Stage II cases need local surgery including carbon dioxide laser treatment with secondary intention healing (see later; Fig. 22.1). Hurley Stage III cases generally require wide surgical excisions of the entire affected region and referral to a Department of Plastic and Reconstructive Surgery.
Evaluation of the various surgical HS treatment procedures is difficult because of incomplete reporting of results and lack of controlled data. Also, the recurrence rate of certain patient material, for example troublesome cases referred to us because no successful treatments have yet been found, varies with the severity of the disease. For surgical studies double-blinded controlled investigations are not useful, and the results of individual techniques are therefore best documented through careful follow-up studies. The terms "wide" and "radical" excision are often poorly defined in published papers, and thus it is difficult to compare and evaluate the methods and results of different published series.
When the papers are written, emphasis is often placed on the technique used to cover an excision defect rather than the extent of excision or the success or failure of the treatment. The need for prolonged follow-up, even after radical surgery, is important to determine late recurrence, as local recurrence is seen for several years after surgery. Early surgical treatment is indicated when medical treatment fails and invariably when the disease is extensive. In established HS there is no evidence that treatment other than surgery has any effect on the natural story of the condition. Only wide surgical excision can cure the patient in the chronic, recurrent stage of the disease. Wide excisions, well beyond the clinical borders of activity, are mandatory, regardless of the localization of HS. The surgical methods chosen in each case depend on several factors, including the region(s) involved , as well as the type and severity of HS [29, 59]. Simple excisions with carbon dioxide laser , primary closure or exteriorization, curettage and elec-trocoagulation [11, 16] of the sinus tracts can be sufficient, but in cases involving the entire apo-crine-gland-bearing area more extensive surgery is sometimes considered necessary [23, 58, 69, 71]. The large wounds from major excisions have either been covered by flaps or meshed grafts, or left to heal by secondary intention [2, 4, 6-8, 10, 11 13-15, 17, 19, 21, 25, 26, 27, 30, 33, 42-44, 49, 50, 52, 55-57, 60, 61, 65, 67]. In 1992, Banerjee reviewed 12 studies with a total of 284 patients, who were treated with various surgical excision methods . The patients selected probably had a somewhat more aggressive clinical type than normal HS patients, since all were hospitalized for 5-42 days after surgery. The follow-up time was 1-8 years and the recurrence rate varied from 0% to 68%. It was concluded that radical excision and healing by secondary intention gave good symptomatic control in axillary, inguino-perineal and perianal regions, but was less satisfactory for the submammary location. Skin grafting and flaps should be reserved for severe recurrent disease . Rompel and coworkers analyzed data from their clinic: 106 HS patients in all (61 women and 45 men) of which 61% were treated in the axillary region, 75% in the inguinal region, 16% in the genito/
perianal region, and 34% in other regions . In a total of 241 surgical procedures the reconstruction type was healing by secondary intention in 20%, primary suture in 41%, local flap in 11%, free skin grafts in 26%, and combinations in 1%. It seems that the patients from Rompel's center generally had less severe disease compared to the above-mentioned material reviewed by Banerjee , since 41% of the procedures were primary sutures. The rate of recurrence within the operated fields was 2.5%, which was not affected by choice of reconstruction method, but rather the severity of the disorder, and there were very few complications. Radical excision was suggested to be the treatment of choice and the use of intra-operative color marking of sinus tracts was reported to minimize recurrence rates .
Incision and drainage, performed in acute situations in various surgeries, are probably the most common treatments for HS patients, and may sometimes lead to temporary control of symptoms; however, they are best avoided since the abscesses almost inevitably recur [3, 6, 10, 55, 58]. Deroofing and exteriorization of the sinus tracts may be of value . Proper exteriorization involves removal of the "roofs" of sinus tracts, removal of all granulation tissue, which in some cases may be rather extensive, and slow healing by secondary intention. It is speculated that optimal exteriorization is highly dependent on the skill and training of the surgeon, and that optimal results may therefore be easier to obtain with an excision. It is common to find large areas of skin undermined with tracks running for long distances, but usually at the same depth. Care must be taken not to create false passages. The complete roof of the track is then cut off, leaving the floor exposed. The true passages are recognizable by their well-established margins and partly epithelialized floor and walls. Care must be taken not to damage the floor of the exposed tracts. In severe cases the treatment is limited at each operating session to an extent that enables mobilization and minimizes postoperative discomfort. Sometimes this method can be used in patients whose disease is so extensive that wide excision could not be contemplated.
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