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Surgical management of hidradenitis suppurativa

Surgical management of hidradenitis suppurativa
Author:
Dennis P Orgill, MD, PhD
Section Editors:
Marc G Jeschke, MD, PhD
Cindy Owen, MD
Deputy Editors:
Kathryn A Collins, MD, PhD, FACS
Abena O Ofori, MD
Literature review current through: Jul 2022. | This topic last updated: Jul 11, 2022.

INTRODUCTION — Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disorder of the folliculopilosebaceous units characterized by the development of inflammatory nodules, pustules, skin tunnels, and scars, primarily in intertriginous areas. Physical pain, odor, chronic drainage, and disfigurement are common features of this disorder.

The surgical management of hidradenitis suppurativa is reviewed here. The clinical features, diagnosis, and medical management are discussed separately. (See "Hidradenitis suppurativa: Pathogenesis, clinical features, and diagnosis" and "Hidradenitis suppurativa: Management".)

GENERAL CONSIDERATIONS — In the setting of refractory HS, surgery may be needed to remove active foci of disease and eliminate scarred tissue sequelae [1-3]. Surgery should not be used in isolation; combining surgery with dietary restrictions and medical therapy provides the best chance for preventing the development of new lesions and controlling disease progress. As surgery is an invasive procedure that will result in additional scarring, prior to proceeding, the risks, benefits, and alternatives should be discussed with the patient.

Surgical procedures may be performed on individual inflammatory nodules, abscesses, or skin tunnels and in severe cases may be necessary to excise an entire affected area [4]. The approach to treating lesions is individualized and becomes more aggressive with higher-stage HS, particularly if medical therapies have not been successful at controlling the disease. (See "Hidradenitis suppurativa: Management", section on 'Summary and recommendations'.)

Surgical techniques used to treat HS are listed and discussed in more detail below.

Punch debridement (See 'Punch debridement' below.)

Unroofing (See 'Unroofing (local or extensive)' below.)

Wide excision (See 'Wide excision and reconstruction' below.)

Incision and drainage (See 'Role of I&D' below.)

Surgery aids in the control of inflammation through several mechanisms by removing epithelialized skin tunnels and associated debris that act as foreign bodies under the skin and removing and draining inflammatory material. Arresting these processes prevents the progressive invasion and tunnel formation that lead to scarring. (See "Hidradenitis suppurativa: Pathogenesis, clinical features, and diagnosis".)

PERIOPERATIVE MEDICATION MANAGEMENT

Preoperative treatment — Medical treatment may be administered to calm inflammation prior to surgical intervention in cases in which the margins of nodules or skin tunnels are difficult to define. The choice of an anti-inflammatory agent before surgery depends upon disease severity.

For mild-to-moderate disease (ie, Hurley stage I or II), systemic antibiotics or anti-inflammatory biologic agents, with or without short courses of prednisone, are used.

For severe disease (ie, Hurley stage III), systemic glucocorticoids (40 to 60 mg per day for two to three days followed by a 7- to 10-day taper) or cyclosporine (4 to 5 mg/kg per day orally) have been used to settle inflammation. Biologic agents, including tumor necrosis factor-alpha (TNF-alpha) inhibitors, may also be used to calm inflammation in patients with severe disease prior to surgery.

Antibiotics — The choice and duration of perioperative antibiotics has not been well studied. For small lesions, many clinicians will continue oral suppressive antibiotics. For larger lesions, intravenous antibiotics that are culture directed can be useful for several days following surgery. (See "Hidradenitis suppurativa: Management".)

LOCAL PROCEDURES — Local surgical procedures (eg, punch debridement, unroofing) are used in conjunction with medical therapies for the management of acutely inflamed nodules and skin tunnels. Based upon observational studies and clinical experience, we suggest unroofing (local or extensive) initially, rather than wide excision for mild-to-moderate HS (ie, Hurley stage I or II). For small nodules, we use the technique of punch debridement (mini-unroofing).

Punch debridement — Punch debridement is our treatment of choice for acute inflammatory nodules, typically in patients with mild or moderate HS (ie, Hurley stage I or II). (See "Hidradenitis suppurativa: Management", section on 'Inflammatory lesions with skin tunnels or scarring (Hurley stage II or III, moderate to severe HS)'.)

Punch debridement is relatively simple and can be easily performed in the office or clinic setting. Punch debridement (mini-unroofing) is centered around a single folliculopilosebaceous unit (FPSU) to evacuate a newly inflamed nodule. The objective of punch debridement is to remove the fractured FPSU in the initial punch with its associated sebaceous glands (if still present) and, more importantly, to remove the "bulge" area of the follicular unit of the FPSU that contains the stem cells hypothesized to be responsible for inducing growth of the proliferative mass and the subcutaneous skin tunnels. The surgical removal of the entire involved FPSU in this manner eliminates the potential for lesion recurrence and prevents the development of the invasive proliferative gelatinous mass that results from follicular rupture and likely leads to tunnel formation [5]. (See "Hidradenitis suppurativa: Pathogenesis, clinical features, and diagnosis", section on 'Mechanism'.)

Punch debridement involves the use of a 5- to 7-mm circular punch instrument (identical to that used in a punch biopsy) to deeply excise the acutely inflamed FPSU within an inflammatory nodule with a small amount of surrounding tissue. This is followed by aggressive debridement using digital pressure and then curettage or simple grattage (scrubbing) with gauze wrapped around a cotton-tipped swab (picture 1). Ferric chloride can be used for hemostasis, and simple petrolatum dressings are applied after the procedure. The wound is allowed to heal by secondary intention [6]. Pain relief and healing are swift.

Unroofing (local or extensive) — Surgical unroofing (also described as deroofing) is indicated for the treatment of inflamed nodules, abscesses, and skin tunnels typically found with moderate and severe HS (ie, Hurley stage II or III). A similar procedure referred to as STEEP (skin-tissue-saving excision with electrosurgical peeling) has been described as an alternative to wide excision for Hurley stage II or III disease that preserves normal tissue while removing the lesions [7,8].

The procedure may be performed on individual nodules or skin tunnels (local unroofing) (picture 2 and picture 3) or on all such lesions in an affected region (extensive unroofing) (picture 4 and picture 5). The technique consists of careful unroofing and debridement of skin tunnels and inflamed tissue by a surgeon experienced with this procedure. Under local or regional anesthesia, skin tunnels or the inflamed cavity are entered through the overlying skin or through a tunnel opening and opened widely with scissors, explored with scissor tips or a malleable metal probe, and serially unroofed until no residual tracts of inflammatory activity remain (movie 1) [9].

The entire roof of each tract should be completely removed and both base and margins explored for hidden entrances to other tunnels. The active proliferative inflammatory mass that is attempting to repopulate the area with new FPSUs must be completely removed by rough gauze grattage (scrubbing) or by sharp curettage with a spoon curette, such as a 6 x 8 mm #0 oval or a Volkmann bone curette. Any residual epithelialized skin tunnel floor may be left exposed to assist healing by secondary intention, or it may be dissected away [9,10]. Ferric chloride solution provides adequate hemostasis. Ferric chloride solution for hemostasis (3.8 molal 37.5% weight/volume ferric chloride anhydrous in water, Delasco) is applied with a cotton swab, then wiped dry, and this is repeated until hemostasis is complete. An electrocoagulation or electrodesiccation device is very occasionally useful for hemostasis or for cutting where appropriate.

Carbon dioxide laser excision with healing by secondary intention can also be used to perform the unroofing of nodules, abscesses, or skin tunnels [11-16]. In one study using this approach, healing took four to eight weeks and the scars were flat and linear [11]. Only one recurrence was noted along the margin of the surgical scar in a previously treated area. In a retrospective review of 185 HS areas in 61 patients, carbon dioxide laser excision appeared effective for healing areas of HS, with recurrences detected in only two treated sites during follow-up periods ranging from 1 to 19 years [12].

Other types of lasers (eg, neodymium: yttrium-aluminum-garnet [Nd:YAG], diode) are nonablative and primarily target the follicular unit, and are not used for unroofing [17-20].

Role of I&D — Routine incision and drainage (I&D) of individual nodules is not an effective or appropriate method for managing HS. I&D provides only short-term relief, and because I&D does not clear the actively growing tissue, lesions treated in this manner tend to recur [3,4,21]. Thus, we convert any situation that suggests the need for I&D into an opportunity to perform a punch debridement (for small, acute inflammatory nodules) or an unroofing procedure (for larger areas of involvement). (See 'Punch debridement' above and 'Unroofing (local or extensive)' above.)

In an early study of 31 patients of whom 6 underwent I&D, the recurrence rate after a mean follow-up period of 72 months was 100 percent [21]. In a retrospective study of 590 patients with HS who were treated surgically at a single institution between 1976 and 2012, patients treated with I&D had a higher recurrence risk than those treated with surgical excision (hazard ratio [HR] 3.5, 95% CI 1.2-10.7) [3]. (See "Techniques for skin abscess drainage".)

Nevertheless, I&D may be needed for the immediate relief of pain in the setting of a tense subcutaneous abscess that is too painful to bear. When necessary, the lesion must be deeply incised. Wide local anesthesia is usually adequate. Packing the wound for a few days is usually needed to prevent premature superficial closure while the wound fills in from below.

The need for repeated I&D should serve as an indicator that initiation of behavioral and dietary modification and medical therapies to control the disease should be undertaken. (See "Hidradenitis suppurativa: Management".)

WIDE EXCISION AND RECONSTRUCTION — Wide excision may be needed to manage an area of chronic or extensive HS (Hurley stage III) when more conservative medical and surgical measures fail [22,23]. Wide local excision is appropriate for extensive chronic lesions. Wide surgical excision using a scalpel or electrosurgical unit entails removal of the entire affected area with margins beyond the clinical borders of disease, combined with continued aggressive medical management is the treatment most likely to achieve the best results [1,4,24-26]. (See "Hidradenitis suppurativa: Management".)

General principles — Wide excision can often substantially change the course of disease. Although not technically curative, many patients will be asymptomatic for long periods of time following resection [27]. The results are often very satisfying for patients with severe disease that is not be adequately controlled with medical or less aggressive surgical therapy [28]. Many patients prefer the more definitive nature of wide excision, particularly if they have been experiencing complications from medical therapies. There is a tradeoff between performing a larger excision (with higher surgical complications and longer times to heal) compared with a smaller excision (with higher risks of developing clinically significant disease adjacent to the excision). (See 'Recurrence' below.)

It is essential to note that wide excision need not be the destructive "en bloc deep to the fascia" technique used in managing extensive soft tissue infection or malignancy. Tissue should be removed that includes the folliculopilosebaceous units (FPSUs) until only soft, normal-appearing subcutaneous fat remains. Removing more than the epidermis, its appendages, skin tunnels, and associated inflammation and scar tissue is only necessary when a true fistula (to a deep structure) is encountered.

The type of anesthetic that is used depends upon the experience of the practitioner and preference of the patient. For smaller excisions in cooperative patients, local anesthesia can greatly simplify the procedure. However, one study suggested that using local anesthesia may be inferior to general anesthesia for wide excision; lower recurrence rates were seen in those who underwent general anesthesia, presumably related to more complete excision from better pain control [29].

The best method of skin closure after wide excision is controversial and largely dependent on the size of the excision. Some prefer healing by secondary intention for even very large excisions. Although effective, this submits patients to long periods of dressing changes that can be painful. Local excision with primary closure (eg, Pollock procedure) is quite useful for smaller excisions, but if the disease is not adequately excised, active disease can then present at the periphery of the excision [30]. In one retrospective study of patients who underwent limited regional excision (resection of abscess and fistula-containing skin in the affected region [n = 14]) or radical wide excision (removal of all hair-bearing skin in the affected region with a clear margin of at least 1 cm [n = 11]), the recurrence rates after a mean follow-up period of 72 months were 43 and 27 percent, respectively [21]. Also, with local excision and primary closure, wound dehiscence is a risk that increases as the excision size increases. The trauma of surgery and the tension of the sutures may activate new lesions along the incision and closure line. We prefer to use mostly subcuticular sutures and dissolvable sutures on the skin to avoid local reactivation of the disease and to avoid pain of suture removal.

With more extensive surgical excision, closure of the skin defect with advancement flaps or split-thickness skin grafting may be needed to accelerate wound healing [31-33]. There are a variety of regional perforator and propeller flaps that can be useful in treating these lesions [34,35]. The choice of a skin graft versus a flap depends on the size of the lesion; the characteristics of the adjacent skin; and the age, sex, and body mass index (BMI) of the patient. (See "Skin autografting" and "Overview of flaps for soft tissue reconstruction".)

A new concept has been introduced that involves "recycled" skin grafts [36-38]. This has been applied to large areas of hidradenitis. In these cases, the surgeon harvests the skin from the resected area, excising the deeper skin and subcutaneous tissue involved in the inflammatory process and then reapplying the skin as a graft (picture 6).

Specific anatomic sites

Axilla — Axillary lesions are one of the most common areas where wide surgical excision is performed [27]. The extent of the excision varies both in terms of area and depth. These excisions need to be approached with caution when approaching the area of the axillary vein since skin tunnels can traverse closely to the vein in the most severe cases.

Primary closure can often be effective for small excisions and for larger excisions in patients who have lost weight. For wounds with modest tension, the wound can be closed over a negative pressure wound healing device that is left in place for two to three days. The patient is then returned to the operating room for removal of the sponge and inspection of the wound. If clean, the remainder of the wound can be closed [39].

For larger lesions, flaps and skin grafts are often used for closure. Flaps have the advantage of providing thicker skin coverage; however, the flap can often be too thick and may require debulking.

When skin grafts are used, they are often meshed to help with the contour of the wound and allow for drainage. Skin grafting is also quite effective but takes longer to heal compared with flaps. For very large areas, flaps are very often not an option, and skin grafts remain the preferred option.

Inguinal/perineal — Lesions commonly also occur in the groin (picture 7) and can also occur in the perineum, labia majora, and scrotum. Skin tunnels in this area can be extensive, and meticulous dissection is required to get a clear removal. In the scrotum, these can track around the spermatic cord. Judgment is needed to determine the extent of excision and type of closure. We follow similar guidelines for closure in the axilla (above).

Gluteal — Gluteal lesions can often be extensive and can either involve the skin or in some cases have extensive subcutaneous tunneling. Radical excision of the tunnels and diseased tissue is necessary to clear the disease.

Perianal — Perianal lesions are challenging as they are near the anus. Local flaps and skin grafts are often necessary to provide coverage in these areas. We generally defer surgical treatment in this region until other areas of the body have been treated. In some cases, lesions located here improve as systemic inflammation from other areas subsides.

Breasts and lower abdomen — Disease on the underside of large breasts and beneath a pannus is frequently seen in patients with obesity. These lesions can be treated with good outcomes using breast reduction surgery or panniculectomy. (See "Overview of breast reduction".)

POSTOPERATIVE CARE AND FOLLOW-UP — Wound closure may be obtained by primary closure at the time of the procedure, delayed primary closure after a period of open wound management, healing by secondary intention, or by using skin graft(s)/skin substitute(s) or flap coverage. The basic principles of open wound management and wound bed preparation prior to skin grafting/skin substitutes and flap reconstruction are reviewed separately. (See "Basic principles of wound management" and "Skin autografting" and "Skin substitutes" and "Overview of flaps for soft tissue reconstruction".)

Dressings for unroofed areas — Generally, for unroofed wounds, simple plain petrolatum is applied to gauze in a very thick (4- to 5-mm) layer, and the resulting nonadherent dressing, laid on or bound to the wound, will suffice as a postsurgical dressing. The petrolatum must cover all surfaces of the gauze to avoid adherence of dry gauze to the wound. Daily (or more frequent) dressing changes involve gentle rinsing of the wound in clear running water, free of soap or cleansers, followed by the reapplication of petrolatum. The gauze is best eliminated from the wound care regimen as soon as possible to avoid scrubbing off newly generated epithelium. The epithelializing margins of the wound must not be debrided or even touched. Loose clothing should be worn to avoid friction in the re-epithelializing areas. After the initial few days, a simple thick application of petrolatum to the wound edges is sufficient. Healing progresses inward from the wound edges and upward from the wound base (picture 8) and may be accelerated in large wounds with skin grafting [40,41].

Negative pressure wound therapy — For managing large open wounds and facilitating adherence of skin grafts or flaps, our preferred method is to use negative pressure wound therapy (NPWT). As with other large open wounds, NPWT has been used successfully in the management of wounds resulting from severe HS [42]. Incisional NPWT devices can also be used over closed incisions, which helps immobilize the skin and removes any exudate from the wound. (See "Negative pressure wound therapy".)

COMPLICATIONS — Complications from surgery can include bleeding, infection-delayed healing, and new disease at the periphery. Resection wounds are highly contaminated, and, if wound complications occur, a combination of intravenous antibiotics and negative pressure wound therapy can be used to manage them.

Recurrence — Recurrence is lowest for wide excision compared with other surgical techniques. In a systematic review, the pooled recurrence rate for wide excision was 8 percent (22 studies, 95% CI 2 to 16 percent). Flap repair following wide excisions had the lowest rate at 0 percent (95% CI 0 to 4 percent) while delayed primary closure had the highest at 38 percent (95% CI 20 to 59 percent) [43]. The recurrence rate for local excision was 34 percent (95% CI 24 to 44 percent). These rates for wide excision were improved from an earlier review in which the estimated average recurrences were 13 percent for wide excision (15 percent for primary closure; 8 percent for flap closure; 6 percent for graft closure) [6]. In this review, the recurrence rate for local incision was 22 percent with local incision and 27 percent with unroofing.

Although many authors use the term "recurrence," in our experience, disease does not "recur" after wide excision but can develop in other areas, either around the previous excision or in other anatomic areas. In a review of 253 hidradenitis excision procedures, recurrence occurred in 37.6 percent [25]. Total remission of an anatomical area was achieved in 49 percent of the procedures, whereas natural disease progression occurred in 13 percent. The genital region was noted to be most prone to recurrence.

If disease comes back adjacent to areas that are widely excised, we will generally refer the patient for medical management and try to space surgeries at least three months apart. If medical management is not successful, in most cases small excisions with direct closure can be used to treat any new disease.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Hidradenitis suppurativa".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Hidradenitis suppurativa (The Basics)")

SUMMARY AND RECOMMENDATIONS

Successful treatment of hidradenitis suppurativa (HS) requires lifelong attention to prevent new lesions in all stages of the disease. Measures to prevent new HS lesions include dietary and behavioral changes and topical or systemic medications, including antibiotics. Surgical interventions may become necessary to manage nodules, abscesses, skin tunnels, and scars. (See 'Introduction' above.)

Surgery should not be used in isolation; combining surgery with dietary restrictions and medical therapy provides the best chance for preventing the development of new lesions and controlling disease progress. (See 'General considerations' above and "Hidradenitis suppurativa: Management".)

Surgical options for management of HS include punch debridement, unroofing of skin tunnels or abscesses, and wide excision. The choice of procedure depends on the severity of the lesion. The evidence supporting these interventions is limited to observational studies and clinical experience. Our approach is generally as follows (see 'General considerations' above):

For acutely inflamed nodules or extensive skin tunnels, we suggest unroofing (local or extensive) combined with medical therapy, rather than wide excision (Grade 2C). For small nodules, we use the technique of punch debridement (ie, mini-unroofing). (See 'Unroofing (local or extensive)' above.)

For patients with chronic or extensive disease, we suggest wide excision of the entire affected area combined with continued aggressive medical management (Grade 2C). Wide excision offers the best chance to provide permanent relief for patients with HS in a localized area that fails to respond sufficiently to medical therapies and that has progressed to a point where surgical unroofing has failed or is unlikely to be sufficient. Some patients with earlier stages of disease may request surgical excision if they become frustrated or have complications related to medical therapies. (See 'Wide excision and reconstruction' above.)

We suggest not performing incision and drainage (I&D) alone for the management of HS except in the setting of a tense abscess when immediate relief of pain is required (Grade 2C). I&D alone is not an effective method for managing HS because lesions treated in this manner tend to recur. (See 'Role of I&D' above.)

ACKNOWLEDGMENTS — The UpToDate editorial staff acknowledges Lynette Margesson, MD, FRCPC, FAAD, who contributed to an earlier version of this topic review.

The UpToDate editorial staff acknowledges F. William Danby, MD, FRCPC, FAAD, now deceased, who contributed to an earlier version of this topic.

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