Surgical Procedures in Hidradenitis Suppurativa

Management of Pilonidal Disease and Hidradenitis Suppurativa

Pilonidal disease and hidradenitis suppurativa affect healthy young adults, causing discomfort and pain that leads to loss of work productivity and should be approached in a personalized manner. Patients with pilonidal disease should engage in hair removal to the sacrococcygeal region and surgical options considered. Hidradenitis suppurativa can be a morbid and challenging disease process. Medical management with topical agents, antibiotics, and biologics should be used initially but wide local excision should be considered in severe or refractory cases of the disease.

A review of surgical and reconstructive techniques for hidradenitis suppurativa

Hidradenitis suppurativa (HS) is an inflammatory follicular dermatological condition that typically affects the intertriginous and anogenital regions of the apocrine gland-bearing skin. The management of this chronic and recurring disease necessitates a combination of lifestyle changes, medication, and surgical approaches to achieve the best possible outcomes. While medical treatments are recommended for this multimodal disease, surgical therapy, which is the gold standard of treatment for HS, has proven to be the most effective treatment because it provides long-lasting local disease control, reduces the recurrence of lesions, and ensures complete healing of lesions. In the last decade, there has been exponential growth in research into various surgical techniques and reconstructive care, enabling patients to have more surgical options. There is a wide range of surgical management procedures available, such as incision and drainage, deroofing, excisional surgery, carbon dioxide laser therapy, and skin tissue-sparing excision with electrosurgical peeling. Among these surgical procedures, wide surgical excision is the best option since it can eradicate all the affected lesions. Meanwhile, the preferred approach to reconstruction at various anatomical locations remains debatable. Here, we review a variety of surgical treatments and reconstructive techniques for HS, particularly various flap techniques for the axillary, gluteal, and inframammary regions.

Differentiating hidradenitis suppurativa flare from infection in the emergency department and recommendations for transitioning care to the outpatient setting

Hidradenitis suppurativa is a painful and often progressive inflammatory skin condition that presents with papules, nodules, abscesses, and tunnels in the axillary, inframammary and anogenital regions. HS can be difficult to differentiate from a skin infection, such as a bacterial abscess. However, differentiation between the two is important as management of hidradenitis suppurativa often requires long-term follow-up and specialist care. Emergency physicians should be aware of how to differentiate acute hidradenitis suppurativa flares from similarly presenting conditions, particularly skin and soft tissue infection, when encountered in the emergency department and what steps should be taken to adequately bridge care to the outpatient setting.

Advances in surgical treatment of hidradenitis suppurative

Hidradenitis suppurative is a chronic, refractory and recurrent dermatological disease. The disease should be managed by targeted surgical intervention on the basis of medical treatment. Currently, the surgical treatment methods include local treatments like incision and drainage, unroofing, laser therapy, intense pulsed light therapy, photodynamic therapy, as well as complete lesion resection such as skin-tissue saving excision with electrosurgical peeling and extended excision. The clearance range, therapeutic effect, postoperative complications, and recurrence risk vary among the different treatment methods. Local treatments cause less damage, but have high recurrence rates, and are mainly for mild to moderate hidradenitis suppurative patients. Complete lesion resections have relatively low recurrence rates, but may bring more surgical injuries, and postoperative reconstructions are needed, which are mainly for moderate to severe hidradenitis suppurative patients. In this article, the surgical treatment principles and various surgical treatment methods of hidradenitis suppurative are reviewed, to provide a reference for the diagnosis and treatment of this disease in clinical practice.

Hidradenitis Suppurativa: An Interdisciplinary Problem in Dermatology, Gynecology, and Surgery-Pathogenesis, Comorbidities, and Current Treatments

Hidradenitis suppurativa (HS), also known as acne inversa, is a chronic inflammatory disease that manifests as painful nodules, abscesses, draining dermal tunnels, and scarring in intertriginous areas such as the axillae, groin, and breasts. The nature of the disease and its chronicity have a destructive impact on mental health and quality of life. HS has an estimated global prevalence of 0.00033-4.1% and it disproportionately affects females compared to males. HS involving the female anogenital regions is reported rarely in the gynecological literature, and it can often be mistaken for other vulvar diseases. The distinct phenotypes and HS rarity cause delayed diagnosis and the implementation of effective treatment. Acne inversa is associated with several comorbidities, including metabolic disease, diabetes mellitus, inflammatory bowel diseases, and spondyloarthropathies. Although HS etiology and pathogenesis remain unclear, studies have shown that lifestyle, immunological processes, genetics, and hormonal predispositions may promote follicular hyperkeratosis, dilatation, and rupture, leading to the development of chronic tissue inflammation. This article provides updated information on HS pathogenesis, comorbidities, and treatment methods. Furthermore, we share our experience in the surgical treatment of the disease, which often proves most effective, and highlight that an interdisciplinary management approach ensures optimal outcomes.

Cervicofacial hidradenitis suppurativa: A case report and literature review

Hidradenitis suppurativa (HS) is a chronic inflammatory condition of the apocrine glands primarily affecting the axillae, perineum, and inframammary regions. It is characterized by painful, inflamed cutaneous lesions causing nodules, sinus tracts, and abscesses. Cervicofacial HS is an atypical presentation of HS in the head and neck region and is scarcely reported in the literature. We present a 34-year-old male who developed a large facial swelling overlying the left inferior mandibular border. Management included surgical incision and drainage, antibiotic therapy, followed by infliximab (Remicade). The purpose of this case report was to highlight the presentation, pathophysiology, interdisciplinary approach to treatment and follow-up of patients with cervicofacial HS, and finally, review the cervicofacial HS literature.

Current Medical and Surgical Treatment of Hidradenitis Suppurativa-A Comprehensive Review

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease presenting with recurrent inflammatory lesions in intertriginous body regions. HS has a pronounced impact on patients' quality of life and is associated with a variety of comorbidities. Treatment of HS is often complex, requiring an individual approach with medical and surgical treatments available. However, especially in moderate-to-severe HS, there is an urgent need for new treatment approaches. In recent years, increased research has led to the identification of new potential therapeutic targets. This review aims to give a comprehensive and practical overview of current treatment options for HS. Furthermore, the clinically most advanced novel treatment approaches will be discussed.

Practical Guidelines for Managing Patients With Hidradenitis Suppurativa: An Update

Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disease that is characterized by the formation of comedones, papules, nodules, abscesses and sinus tracts in the axillary, inframammary, groin, and gluteal areas. Up to 3.8% of the Canadian population has HS, though due to a lack of awareness of HS, many patients are initially misdiagnosed and do not receive adequate treatment early on in the disease course. Once a diagnosis of HS is made, developing an effective management plan can be a dilemma for many providers. There is significant variability in response to any given therapy within the HS patient population and many HS patients have other medical comorbidities which must be taken into consideration. The aim of this review is to provide a practical approach for all healthcare providers to diagnose and manage HS and its associated comorbidities. A sample electronic medical record template for HS management was developed by the Canadian Hidradenitis Suppurativa Foundation Executive Board and is intended for use in clinical settings. This will help to increase collaboration between primary healthcare providers, dermatologists, and other medical specialists and ultimately improve the quality of care that HS patients receive.

Surgical Treatment in Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic, progressive inflammatory disorder of follicular occlusion with pubertal onset that presents as painful inflammatory nodules, sinus tracts, and tunnelling in apocrine-gland-rich areas, such as the axilla, groin, lower back, and buttocks. The disease course is complicated by contractures, keloids, and immobility and is often associated with a low quality of life. It is considered a disorder of follicular occlusion with secondary inflammation, though the exact cause is not known. Management can often be unsatisfactory and challenging due to the chronic nature of the disease and its adverse impact on the quality of life. A multidisciplinary approach is key to prompt optimal disease control. The early stages can be managed with medical treatment, but the advanced stages most likely require surgical intervention. Various surgical options are available, depending upon disease severity and patient preference. In this review an evidence-based outline of surgical options for the treatment of HS are discussed. Case reports, case series, cohort studies, case-control studies, and Randomized Clinical Trials (RCT)s available in medical databases regarding surgical options used in the treatment of HS were considered for the review presented in a narrative manner in this article.

Patient Impressions and Outcomes After Clinic-Based Hidradenitis Suppurativa Surgery

IMPORTANCE

Surgical intervention is frequently needed to treat hidradenitis suppurativa (HS). Patient satisfaction is high based on previous studies, but reports of patient impressions of clinic-based operative experiences and postoperative recovery are limited.

OBJECTIVE

To characterize patient impressions, outcomes, and recovery time after clinic-based surgical treatment of HS and examine patient characteristics associated with outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included patients 12 years or older who underwent clinic-based surgical procedures for treatment of HS at a single subspecialty HS clinic at the University of North Carolina Department of Dermatology from April 2014 to December 2018. Data analysis was performed from January to September 2021.

EXPOSURES

Clinic-based deroofing and excisional procedures performed as part of routine care.

MAIN OUTCOMES AND MEASURES

The primary outcomes were patient-reported recurrence of HS at the site of surgery, patient satisfaction with the procedures and outcomes, and patient-reported pain and recovery associated with surgery obtained from electronic medical record review and patient questionnaires.

RESULTS

Outcomes of 194 procedures for 78 patients (65 [83%] female; mean [SD] age, 35.1 [12.1] years) were analyzed. Self-reported rate of recurrence was 41% (79 procedures). Despite recurrence, most patients (148 procedures [76%]) were very satisfied with their surgical results. The median number of missed days of work or school was 2 (IQR, 1-7 days), and the median number of days until return to normal activity was 10 (IQR, 3-14 days). In addition, for 126 of the 194 procedures (65%), patients stated that pain during an HS flare was worse than pain during surgical recovery.

CONCLUSIONS AND RELEVANCE

In this cohort study, patients reported high rates of satisfaction with clinic-based HS surgery. Recovery was typically rapid, with most patients rating postsurgical pain as less severe than their HS pain.

Damage in Hidradenitis Suppurativa: A Narrative Review Emphasizing the Need for a Novel Outcome Measure

Cutaneous damage caused by hidradenitis suppurativa is an important contributor to disease burden, independent of active lesions. Outcome measures used to specifically assess damage are becoming commonplace in assessment of inflammatory diseases. However, no standardized method for assessing HS damage currently exists. The purpose of this study was to review outcome measures in HS that include constructs of both active disease and damage, review damage-specific instruments used in other inflammatory and destructive diseases, and review instruments used to assess scars of various etiologies. This ultimately provides insight into how attributes of different tools can be applied to develop an outcome measure specific to HS damage.

Biologic Use in Pediatric Patients With Hidradenitis Suppurativa: A Systematic Review

BACKGROUND

There is currently at least 1 biologic (adalimumab) approved in North America for treatment of Hidradenitis Suppurativa in the pediatric population. However, no reviews or clinical trials have specifically analyzed the effectiveness and safety data of biologic use in this population. The objective of this systematic review is to identify and summarize the outcomes of biologic therapy in pediatric patients with HS.

METHODS

MEDLINE and EMBASE databases were used to conduct the search on Sept 18, 2020.

RESULTS

The 15 included studies consisted of 26 patients, with the mean age of 15 ± 2.3 years. Females accounted for 53.8% (n = 14/26) of cases. The mean duration of HS prior to biologic initiation was 3.5 ± 2.9 years, with the majority having Hurley Stage II. The 26 patients received 34 biologics in total: 85.3% treated with TNF alpha inhibitors (adalimumab n = 17, infliximab n = 10, etanercept n = 1, unspecified n = 1), 5.9% with IL-12/23 inhibitors (ustekinumab n = 2), 5.9% with IL-1 inhibitors (i.e., anakinra n = 2) and 2.9% received IL-23 inhibitors (i.e., guselkumab n = 1) biologics. Of the 26 patients, 23.1% (n = 6/26) experienced complete resolution (CR), 73.1% (n = 19/26) experienced partial resolution (PR), and 3.8% (n = 1/26) had no resolution outcomes reported. The time to resolution of HS lesions after biologic initiation ranged from 10 days to 11.5 months (mean: 5.1 months). No adverse events were reported in the studies.

CONCLUSION

Although anti-TNF alpha were the most common biologics used for HS in pediatric cases, large-scale trials specific to pediatric patients with HS are needed to confirm these findings.

Current Surgical Management of Hidradenitis Suppurativa: A Systematic Review and Meta-Analysis

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic dermatologic condition that often necessitates surgical treatment. Surgical approaches vary substantially with little data on efficacy and safety.

OBJECTIVE

Summarize the literature on HS surgery with regards to patient characteristics, surgical approaches, and study quality. Compare postsurgical recurrence rates with a meta-analysis.

METHODS

PubMed, Embase, and Scopus were searched for studies on surgical HS management published after 2004. A random effects meta-analysis of recurrence rates was performed on eligible studies.

RESULTS

Of 715 identified studies, 59 were included in the review and 33 in the meta-analysis. Twenty-two studies of wide excision had the lowest pooled recurrence rate at 8% (95% confidence interval [CI] 2%-16%); local excision had the highest at 34% (95% CI 24%-44%). For studies of wide/radical excision, flap repair had the lowest pooled recurrence rate at 0% (95% CI 0%-4%); delayed primary closure had the highest at 38% (95% CI 20%-59%).

CONCLUSIONS

Wide excision and flap-based reconstruction are associated with a lower postsurgical HS recurrence, although this must be balanced against potentially higher morbidity of extensive procedures. Heterogeneity and methodological limitations of the evidence limit the ability to make a strong conclusion about the relative recurrence rates associated with surgical techniques.

REGISTRATION

PROSPERO ID: CRD42020159948.

Hidradenitis suppurativa: Basic considerations for its approach: A narrative review

Hidradenitis suppurativa is a chronic and debilitating skin disease, whose lesions can range from inflammatory nodules to abscesses and fistulas in the armpits, groin, perineum, inframammary region. Diagnosis can be confused with a large number of clinical pictures, and although studies on hidradenitis suppurativa are not so scarce in the literature, doctors are often unaware of this disease and therefore its diagnosis is often late. Pharmacological treatment ranges from retinoids to immunosuppression and radiation therapy, and surgical treatment ranges from incision and drainage to more complete excisions and laser therapies. Hidradenitis suppurativa is a disease seen and treated mainly by dermatologists and general surgeons, however, it is necessary for general practitioners to have basic knowledge about this entity, as they are the first line of care in the health system.

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Hidradenitis suppurativa is an entity of necessary recognition by the surgeon.

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It is a preventable and treatable condition with a good prognosis.

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This condition should be managed by a multidisciplinary team.

[Hidradenitis suppurativa /acne inversa-surgical options, reconstruction and combinations with drug therapies-an update]

Hidradenitis suppurativa/Acne inversa (HS/AI) ist eine chronisch-entzündliche Hauterkrankung, deren Behandlung sowohl konservative als auch chirurgische Behandlungsmöglichkeiten umfasst. In den Hurley-Stadien II und III ist die chirurgische Resektion irreversibel zerstörten Gewebes anzustreben. Hierzu existieren verschiedene Resektionstechniken, die sich vor allem in ihrer Invasivität und Rezidivneigung unterscheiden. Bis heute gibt es keinen allgemein akzeptierten Konsens hinsichtlich verschiedener Resektions- und Rekonstruktionstechniken sowie der Einbeziehung medikamentöser Therapien in das therapeutische Gesamtkonzept.

Integrated multidisciplinary approach to hidradenitis suppurativa in clinical practice,

Background

The European hidradenitis suppurativa (HS) guidelines recommend a multidisciplinary approach for patients with HS and management of comorbidities.

Objective

We aimed to describe the organization of a multidisciplinary HS program and characterize the patient population.

Methods

We conducted a retrospective study of patients with HS undergoing prospectively defined multidisciplinary work-up including examinations by a dermatologist, plastic surgeon, smoking specialist, and nutritionist in our outpatient unit between October 2015 and January 2017.

Results

The study included 49 patients with a sex ratio of 1:1. A total of 73.4% of patients were smokers, 20.4% were overweight, 48.9% were obese, and 30.6% had symptoms of depression. The mean Sartorius score was 30.4 (±17.6). The outcome of plastic surgery consultation was as follows: 16 patients had operations, 5 were excluded based on medical history, 9 refused surgery, and 16 remained undecided. The refusal rates for consulting with the smoking cessation and nutrition specialists were 55.8% and 69.5%, respectively. Twelve patients received antibiotics, 9 received biologics, 9 underwent medico-surgical treatment, 9 underwent surgery, and 10 were lost to follow-up. The mean visual analogue scale score for satisfaction was 8.3 (±1.6; n = 28).

Conclusion

An integrated multidisciplinary care model for HS is associated with high patient satisfaction. Adherence to the proposed comorbidity management was higher in female patients and related to empathetic interactions with physicians.

Office-Based Surgical Intervention for Hidradenitis Suppurativa (HS): A Focused Review for Dermatologists

Easily accessible office-based procedures that require minimal resources may facilitate timely surgical management of hidradenitis suppurativa (HS). This review focuses on excision and unroofing as two surgical HS treatments that can be tailored to the outpatient setting. Fifty-five articles were included in our review, representing 3914 patients. The majority were retrospective studies (58%, n = 32), and the studies reported data both across patients and by number of treated lesions. Recurrence rates for unroofing (14.5%) were found to be half that of excision (30%) across patients (p = 0.015) and slightly lower across lesions [20% recurrence vs 26% for excision (p = 0.023)]. Complication rates at the lesion level were also significantly associated with procedure, with rates after excision more than double those after roofing (26% vs. 12%, p < 0.001). The complication rate after combined medical and surgical therapy did not differ between procedures. Studies also suggest that continuing medical therapy in the perioperative period may be associated with improved recurrence rates, although delayed wound healing with biologic therapy has been reported. The existing data are limited by low-quality uncontrolled studies with small sample sizes, variable reporting of outcomes, and lack of uniform definitions for recurrence and remission. Further systematic prospective studies are needed to better compare complication and recurrence rates across these procedures in HS, especially in the context of concomitant medical therapy.

Hidradenitis Suppurativa: Surgical and Postsurgical Management

Background

Hidradenitis suppurativa (HS) is a chronic inflammatory disorder. Several medical treatments, with varying degrees of efficacy, have been developed. However, in most cases of advanced HS, the definitive treatment option is often represented by surgical excisions.

Objective

Surgical techniques, reconstructive approach, and local wound care should be accurately designed in order to obtain the best result. In this review we analyze the possible surgical treatments and local wound care.

Methods

A MEDLINE search was performed on the various surgical treatments, reconstructive techniques, and local wound care.

Results

Surgical treatment is a common therapeutic modality for HS. Different surgical reconstructive techniques and post-surgical wound care approaches are described for the management of HS patients.

Conclusions

There were few high-quality evidence-based studies evaluating the surgical management of HS. Many disparate HS severity scores were used in these studies, making comparisons between them difficult. Nonetheless, research on different surgical approaches and wound care management has increased substantially in the past decade and it has given patients more surgical therapeutic strategies. The description of the best combinations and timing of surgery, wound care, and medical therapies will be a matter of future research for the definition of the optimal management of the HS patient.

Comparison of Split Thickness Skin Grafts and Flaps in Bilateral Chronic Axillary Hidradenitis Suppurativa

BACKGROUND

Hidradenitis suppurativa is a chronic inflammatory disease with multiple inflammatory nodules and abscesses. We aimed to compare split thickness skin graft (STSG) and flaps in bilateral chronic refractory axillary hidradenitis suppurativa.

METHODS

Thirty patients were investigated from March 21, 2010 to March 20, 2015. Debridement of involved skin and subcutaneous fat was done until deep fascia. The second operation was a reconstructive procedure to cover bilateral axillary wounds with STSG in left side and random fasciocutaneous flaps in the right side.

RESULTS

Mean age of patients was 35.2±9.3 years. There were 16 men (53.3%) and 14 women (46.7%). Duration of the disease before trial was 6.5±2.1 years. The association between pain at one-month follow-up for graft or flap sites was not significant. The patients did not have pain at flap and graft sites at three-month, six-month and one-year follow-ups. Twenty-four patients (80.0%) had normal ranges of motion at one-month follow-up. At six-month and one-year follow-ups, all patients had bilateral normal ranges of motion. All patients were satisfied from symmetry of flap and graft sites at six-month and one-year follow-ups. All patients were satisfied from graft and flap donor sites at six-month and one-year follow-ups. At one-month, three-month, six-month and one-year follow-ups, recurrence of hidradenitis suppurativa was not seen.

CONCLUSION

Both STSGs and fasciocutaneous flaps were successful and satisfactory for tissue coverage in patients with axillary hidradenitis suppurativa. We recommend this technique in cases of bilateral axillary hidradenitis suppurativa.

Hidradenitis suppurativa

Hidradenitis suppurativa (HS; also designated as acne inversa) is a chronic inflammatory disorder, which affects the intertriginous skin and is associated with numerous systemic comorbidities. The estimated prevalence of HS is ~1% in most studied countries. Typically starting in early adulthood, cutaneous inflamed nodules, abscesses and pus-discharging tunnels develop in axillary, inguinal, gluteal and perianal body sites. The comorbidities of HS include metabolic and cardiovascular disorders, which contribute to reduced life expectancy. A genetic predisposition, smoking, obesity and hormonal factors are established aetiological factors for HS. Cutaneous changes seem to start around hair follicles and involve activation of cells of the innate and adaptive immune systems, with pivotal roles for pro-inflammatory cytokines such as tumour necrosis factor, IL-1β and IL-17. The unrestricted and chronic immune response eventually leads to severe pain, pus discharge, irreversible tissue destruction and scar development. HS has profound negative effects on patients' quality of life, which often culminate in social withdrawal, unemployment, depression and suicidal thoughts. The therapeutic options for HS comprise antibiotic treatment, neutralization of tumour necrosis factor and surgical intervention together with lifestyle modification. Nevertheless, there is an enormous need for awareness of HS, understanding of its pathogenesis and novel treatments.

Pediatric Endoscopic Hidradenitis Treatment: A New Minimally Invasive Treatment for Pediatric Patients with Hidradenitis Suppurativa

Background: Hidradenitis suppurativa (HS) is infrequent in the pediatric population. When indicated, surgery is often invasive, painful, and with significant recurrence rate. We aimed to report our preliminary experience using a new endoscopic technique to treat this pathology. Materials and Methods: We reported the data of 11 patients (9 girls and 2 boys) with average age of 15.7 years (range 14-17) with HS, who were operated using endoscopic procedure for a 15-month period. Six patients presented axillary, inguinal, and inframammary localizations, 3 patients presented axillary and inguinal localizations, and 2 patients presented only inguinal localization. Pediatric endoscopic hidradenitis treatment (PEHT) followed the same principles of pediatric endoscopic pilonidal sinus treatment (PEPSiT). The fistuloscope was introduced into the different holes, and after using an endobrush, all tracts were cauterized using monopolar electrode or laser energy, and finally the granulation tissues were removed using graspers. At the end of the procedure, all the holes were filled with oxygen-enriched oil-based gel and covered with fat gauze. Results: The average operative time was 47 minutes (range 30-80). All procedures were performed in a day surgery setting or with an overnight hospitalization. All patients reported no pain postoperatively and performed a local dressing with silver sulfadiazine spray and oxygen-enriched oil-based gel two times per day for 1 month postoperatively. At the longest follow-up of 1 year, the lesions were completely healed in all cases. Two patients (18%) developed further lesions in different untreated localizations that were successfully treated using PEHT. Conclusions: PEHT is a minimally invasive, effective, and safe treatment option for pediatric patients with HS. All patients reported a painless postoperative period and excellent results. Postoperative local dressings using oxygen-enriched oil-based gel and silver sulfadiazine spray are fundamental to achieve the complete healing. However, a further evidence with larger series and longer follow-up is required to confirm these preliminary results.

Factors Affecting Healing in the Treatment of Hidradenitis Suppurativa

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic debilitating condition. Treatment of HS depends on disease stage, goals of care, access to care, and frequency of symptoms. We present our experience with surgical treatment for patients with HS.

METHODS

Patients were followed longitudinally for at least 2 years postsurgical intervention. Demographic data, participation in a multidisciplinary program, type of surgery, healing rates, and potential factors contributing to wound healing were retrospectively reviewed in all cases using multivariate analysis.

RESULTS

Two hundred forty-eight patients met the inclusion criteria with a total of 810 involved sites. Overall, 59% of patients had Hurley stage 3 disease at the time of surgery. Healing rates of 80% were observed in stages 1 and 2, and 74% were observed in stage 3. Hurley stage was not a significant predictor of healing (P = 0.09). Surgical treatment consisted of 38% incision and drainage, 44% excision without closure, and 17% excision with primary closure. Incisional and excisional treatments healed 78% and 79%, respectively, at 2 years. Primarily repaired defects (grafts and flaps) were 68% healed at 2 years. Observed healing rates were uniform regardless of the number of sites involved (P = 0.959). Participation in the multidisciplinary program was the strongest predictor of healing (78% vs 45%, P = 0.004). Sex, age, body mass index, tobacco use, diabetes, presurgery hemoglobin, and family history of HS were statistically not significant. Continuation of immune modulating therapy within 2 weeks of surgery was a predictor of reduced healing (odds ratio, 0.23; P = 0.004), whereas holding biologics for at least 2 weeks was not significant (odds ratio, 1.99; P = 0.146).

CONCLUSIONS

Participation in a multidisciplinary program is a strong predictor of long-term success when treating HS. Hurley score and number of involved sites did not correlate with successful healing after surgery. If taking biologics, we identified 2 weeks as an appropriate break from biologics before and after surgical intervention. Healing rates were highest with ablative procedures (incision and drainage, excision) alone.

Hidradenitis suppurativa: Current and emerging treatments

The treatment of hidradenitis suppurativa (HS) has remained challenging because of the many knowledge gaps regarding etiology. However, recent studies into the pathogenesis of HS have enabled the investigation of newer therapies. The second article in this continuing medical education series reviews the evidence for established therapies for HS, including anti-inflammatories, antibiotics, and surgery. New and emerging therapies that specifically target cytokines involved in HS pathogenesis will be covered. The potential therapeutic roles of anticytokine therapies, including both the expanded application of existing molecules as well as the specific development of novel therapies for HS are discussed. With increased attention on HS and with numerous clinical trials currently underway, we hope that the variety of treatment options for HS will be expanded.

Miscellaneous Perianal Afflictions

This article provides an overview of hidradenitis suppurativa, lichen planus, lichen sclerosis, calcinosis cuti, pyogenic granuloma, intertrigo, and seborrheic keratosis. This article also focuses on recognition and management of these pleomorphic afflictions of the perianal region.

North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations: Part I: Diagnosis, evaluation, and the use of complementary and procedural management

Hidradenitis suppurativa is a chronic inflammatory disorder affecting hair follicles, with profoundly negative impact on patient quality of life. Evidence informing ideal evaluation and management of patients with hidradenitis suppurativa is still sparse in many areas, but it has grown substantially in the last decade. Part I of this evidence-based guideline is presented to support health care practitioners as they select optimal management strategies, including diagnostic testing, comorbidity screening, and both complementary and procedural treatment options. Recommendations and evidence grading based on the evidence available at the time of the review are provided.

[Surgical treatment options for hidradenitis suppurativa/acne inversa]

Hidradenitis suppurativa/acne inversa (HS/AI) is a chronic inflammatory skin disease. Therapy consists of conservative and surgical treatment options. In Hurley stages II and III, surgical intervention is regarded as the method of choice for areas with irreversible tissue destruction. Resection techniques with different grades of invasiveness are described in the literature. Nevertheless, there is no generally accepted concept regarding resection and reconstruction techniques or specific postoperative care. Due to lack of definitions of recurrence after surgery and poor study quality, recurrence rates are difficult to determine.

Treatments for hidradenitis suppurativa

Hidradenitis suppurativa (HS) is not easily treated. Although not uncommon, HS is often misdiagnosed outside specialized clinics and inappropriately treated as a simple boil or abscess. In recent years, guidelines have been developed on the basis of expert opinion and the available literature. A multifaceted approach is necessary as HS lesions include both inflammation (amenable to medical treatment) as well as fibrosis (amenable to surgery only). The recommended antiinflammatory therapies encompass both antimicrobials and regular anti-inflammatory drugs. We have, therefore, reviewed treatments with the following agents: clindamycin, tetracycline, rifampicin, ertapenem, dapsone, triamcinolone, infliximab, adalimumab, and anakinra. The development of new medical treatments, however, is an ongoing effort, and important new data have been presented since the publication of the guideline. The current approach to the management of fibrotic lesions is surgery. It is important, as manifest fibrosis is generally not susceptible to medical treatment. Here minor excision, carbon dioxide-laser, and major surgery are discussed, and current evidence supporting their use is provided. A comprehensive three-pronged approach with adjuvant therapy, medical therapy, and surgery is recommended. The importance of adjuvant therapy, that is, pain management, wound care, and attention, is stressed. Adjuvant therapy not only plays a major role in patients' perception of a successful treatment but also is of practical importance to their coping and self-management. HS presents a significant unmet need, and this review provides a mechanistic update on the current real-world therapeutic option for the management of this distressing disease.