Surgical management of hidradenitis suppurativa: procedural trends and risk factors

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.

Comparison of Negative Pressure Wound Therapy with or without a Split-Thickness Skin Graft in the Surgical Management of Axillary Hidradenitis Suppurativa: A Retrospective Cohort Study

Introduction: Negative pressure wound therapy (NPWT) alone or with the addition of a split-thickness skin graft (STSG) are 2 reconstructive options available after surgical excision of axillary hidradenitis suppurativa (HS). The aim of this study was to retrospectively examine patients undergoing these treatments and to assess clinical and patient-related outcome measures. Methods: A single-centre, retrospective analysis was conducted, evaluating surgical excision of axillary HS, with STSG and NPWT, or NPWT alone. Data collected included No. of post-operative clinic visits, time to heal, size of wound, disease recurrence, follow-up time, Dermatology Life Quality Index (DLQI), the Generalised Anxiety Disorder Assessment (GAD-7), the Patient Health Questionnaire Depression Scale (PHQ-9), Pain Visual Analogue Scale (PAINVAS2), the Brief Illness Perception Questionnaire (BIPQ), and Dermatology Visual Analogue Scale (DERMVAS). Two-tailed t-test and Mann-Whitney Wilcoxon U-tests were used to assess for significant relationships. Results: One hundred five patients were included in the study, 44 who received NPWT alone, and 61 who received NPWT + STSG. There was no significant difference in follow-up time (P = .934) or No. of follow-up appointments between groups (P = .287). There was a significant difference in time to heal between groups, with STSG + NPWT observing a mean time of 2.77 months and NPWT alone observing a mean time of 4.40 months (P = .0006). There was no difference in patient-reported outcomes between the 2 groups. Conclusion: There is no difference in patient-reported outcomes with the addition of an STSG to NPWT after surgical excision of HS. Wide excision and use of NPWT alone is an effective procedure for the treatment of axillary HS.

Characteristics and Outcomes of Patients Undergoing Surgical Management of Hidradenitis Suppurativa: An ACS-NSQIP Data Analysis

Objective: Hidradenitis suppurativa (HS) is a painful inflammatory skin disease. Management is largely medical, with surgery reserved for severe refractory cases. In this study, we sought to conduct a retrospective analysis of a multi-institutional surgical database to investigate the surgical management of patients with HS and identify trends in the postoperative outcomes. Approach: The 2011-2019 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was reviewed to identify patients who underwent surgery for management of HS. Postoperative outcomes were assessed, including surgical and medical complications, length of hospital stay, reoperation, readmission, and nonhome discharge. This article was reported according to the STROBE criteria. Results: We identified 1,030 patients, of which 62% were female and 50% were black. The most common comorbidity was obesity (61%). Surgery was mainly performed by general surgeons (62%) and plastic surgeons (31%). Complications were overall low, with readmission being the most common (7.1%, unplanned 6.0%), followed by reoperation (5.8%). The most common surgical complication was superficial incisional infection (5.1%) and most common medical complication was sepsis (3.8%). Obesity is seen to affect surgical complication rates, with patients with obesity having higher rates of dehiscence (obese: 3.1% and nonobese: 1.0%; p = 0.03) but lower rates of organ space infection (obese: 0.5% and nonobese: 2.0%; p = 0.03) and transfusion (obese: 2.5% and nonobese: 5.2%; p = 0.04). A focus on complications in patients undergoing flap reconstruction (n = 293; 23%), identified higher rates of surgical complications, with superficial incisional infection being the most common (flap reconstruction: 7.5% and incision and drainage, debridement, skin graft: 4.1%; p = 0.04). Innovation: The surgical management of HS is analyzed at the national level, with postoperative complications seen to depend on race and obesity-status. Conclusions: Surgical management for HS is associated with low postoperative complications, making surgery a viable treatment option for this debilitating disease.

Phenotype Algorithms to Identify Hidradenitis Suppurativa Using Real-World Data: Development and Validation Study

BACKGROUND

Hidradenitis suppurativa (HS) is a potentially debilitating, chronic, recurring inflammatory disease. Observational databases provide opportunities to study the epidemiology of HS.

OBJECTIVE

This study's objective was to develop phenotype algorithms for HS suitable for epidemiological studies based on a network of observational databases.

METHODS

A data-driven approach was used to develop 4 HS algorithms. A literature search identified prior HS algorithms. Standardized databases from the Observational Medical Outcomes Partnership (n=9) were used to develop 2 incident and 2 prevalent HS phenotype algorithms. Two open-source diagnostic tools, CohortDiagnostics and PheValuator, were used to evaluate and generate phenotype performance metric estimates, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value.

RESULTS

We developed 2 prevalent and 2 incident HS algorithms. Validation showed that PPV estimates were highest (mean 86%) for the prevalent HS algorithm requiring at least two HS diagnosis codes. Sensitivity estimates were highest (mean 58%) for the prevalent HS algorithm requiring at least one HS code.

CONCLUSIONS

This study illustrates the evaluation process and provides performance metrics for 2 incident and 2 prevalent HS algorithms across 9 observational databases. The use of a rigorous data-driven approach applied to a large number of databases provides confidence that the HS algorithms can correctly identify HS subjects.

Our Experience in Using Lateral Chest Flap to Treat Axillary Hidradenitis Suppurativa

Hidradenitis suppurativa is a chronic inflammatory condition that affects apocrine gland-bearing areas' causing abscesses and sinuses. Multimodality treatment is suggested for management. The surgical option is becoming more widely used, especially in drug-resistant cases. In this article, we describe a series of bilateral axillary hidradenitis cases which we treated with wide local excision and immediate reconstruction with lateral chest flap.

Methods

Fourteen patients presented to our clinic with bilateral hidradenitis suppurativa of the axilla. The cases were all resistant to medical treatment. They were managed by excision and simultaneous reconstruction with lateral chest flaps.

Results

At 3 months postoperatively, all patients had full shoulder range of motion and were completely satisfied with the aesthetic outcome, except for one patient who complained of the bulky look of his axilla. Liposuction was performed for him' with a pleasant resultant outcome.

Conclusions

Our patients underwent wide local excision of bilateral disease plus reconstruction with lateral chest flaps in the same session. Our aim was to introduce a treatment option for moderate to severe axillary hidradenitis suppurativa that offers good aesthetic and functional outcomes.

Exploring Access to Surgical Interventions for Hidradenitis Suppurativa: Retrospective Population-Based Analysis

BACKGROUND

Hidradenitis suppurativa (HS) is a painful inflammatory disorder that confers significant distress to patients, with surgery as an integral treatment modality.

OBJECTIVE

To inform improvements in care, patterns in HS surgery were assessed.

METHODS

A retrospective population-based analysis was performed on Ontario billing claims for HS surgery across a period of 10 years from January 1, 2008 to December 31, 2017. HS surgery was defined as the excision of inguinal, perineal, or axillary skin and sweat glands for hidradenitis. The top 5 billing specialties, including general and plastic surgery, were analyzed. The total number of procedures performed as well as the number performed per physician were investigated. Patient and physician locations were compared.

RESULTS

A total of 7195 claims for the excision of inguinal, perineal, or axillary skin and sweat glands for HS were submitted across the study period. Annual HS surgery claims showed an increasing trend across 10 years, ranging between 4.9 and 5.8 per 100,000 population. However, overall, for every additional year, the number of claims per 100,000 population only increased slightly, by 0.03 claims. The number of providers steadily decreased, ranging between 1.7 and 1.9 per 100,000, with approximately twice as many general than plastic surgeons. However, again overall, for every additional year, the number of providers per 100,000 population decreased slightly, by 0.002 physicians. The mean annual number of procedures per physician rose from 2.8 to 3.1. In rural areas, analyzed per claim, general surgeons performed the majority of surgeries (1318/2003, 65.8%), while in urban areas, surgeries were more equally performed by general (2616/5192, 50.4%) and plastic (2495/5192, 48.1%) surgeons. Of HS surgery claims, 25.7%-35.9% were provided by a physician residing in a different area than the patient receiving care.

CONCLUSIONS

No significant improvements in access to HS surgery were seen across the study period, with access potentially worsening with annual HS claims rising overall and number of providers decreasing, with patients travelling further to access surgery. System barriers across the continuum of HS diagnosis and management must be evaluated to improve access to surgical care.

Plastic Surgical Management of Hidradenitis Suppurativa

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the pathogenesis of hidradenitis suppurativa. 2. Discuss perioperative multimodal therapy of hidradenitis suppurativa, including medical optimization. 3. Determine an appropriate surgical plan with excision and reconstruction based on hidradenitis suppurativa severity, size, and anatomical location.

SUMMARY

Successful treatment of hidradenitis suppurativa requires a multidisciplinary team approach and multimodal therapy.

Systematic Review of Complications and Recurrences After Surgical Interventions in Hidradenitis Suppurativa

BACKGROUND

The possible connection between hidradenitis suppurativa (HS) patients undergoing surgery and higher complications/recurrences has been implied, but inconsistent results reported.

OBJECTIVE

To assess the complication and recurrence rates for HS patients undergoing surgery and to evaluate whether known HS comorbidities and habits (smoking, obesity and diabetes) have an effect on the complication and recurrence rates.

MATERIALS AND METHODS

A systematic review was conducted by 2 reviewers. PubMed and Embase were searched using a predefined search string created in collaboration between the authors and a librarian on January 23, 2019.

RESULTS

Of the 271 references in the original search, 54 relevant articles were identified. This systematic review indicates an overall mean complication rate of 24% and a mean recurrence rate of 20.1% for HS patients undergoing surgery.

CONCLUSION

No significant association between the known surgical risk factors and surgical complications-or recurrence rates in this patient group was found. This review revealed a lack of quality and quantity data in studying the complications/recurrences. The heterogeneity of the studies created limitations, and the presented mean complication/recurrence rates should be interpreted with the consequences thereof. It elucidates the need for better studies and a necessity for a standardized definition of postsurgical HS recurrence.

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.

Reconstruction for axillary hidradenitis suppurativa using one-stage local tissue rearrangement: A retrospective analysis of 53 cases

Wide local excision offers a potential cure for severe axillary hidradenitis suppurativa. However, the gold standard for reconstruction has yet to be defined. Here, we describe our rotation advancement flap technique, which allows for one-stage closure of large axillary defects, with minimal functional morbidity to the axilla. We performed a retrospective review of all patients who underwent one-stage surgical management for axillary hidradenitis suppurativa at a single-centre tertiary care hospital from 2009 to 2018. We identified 34 patients, with a total of 53 operative sites. The majority were female (85%) with a mean age of 31 years and body mass index 35 kg/m² . The median defect size was 84 cm² and the majority were treated using the rotation advancement flap technique (86%). A quarter of operative sites experienced minor complications with only one requiring re-operation. At a median follow-up of 32 months, two (4%) sites showed decreased range of motion. However, all patients had achieved remission without any further recurrence of disease. We describe a one-stage rotation advancement flap technique for management of moderate to severe hidradenitis suppurativa that achieves a high local cure rate, minimal functional morbidity, and acceptable wound complication rates.

Factors influencing the local cure rate of hidradenitis suppurativa following wide local excision

Wide local excision is the gold standard and only potential curative therapy for recalcitrant hidradenitis suppurativa. However, high recurrence rates persist even post-surgery with little known on the influencing factors for remission. We evaluated the effect of patient, disease, and operative factors on local cure rate of moderate to severe hidradenitis following wide local excision. We performed a retrospective chart review for all patients who had undergone surgical excision of hidradenitis at a university hospital from 2012 to 2018. We identified 79 patients with a total of 220 operative sites. The majority were obese (mean body mass index [BMI] 32.5), female (71%), African-American (84%), and had a mean age of 31 years. A quarter of operative sites experienced a recurrence (n = 56). Patients who achieved remission had a significantly lower number of affected regions than those who experienced a recurrence (2.3 vs 3.6, P = .0023). Additionally, recurrence rate differed significantly between body locations (P = .0440). Smoking, BMI, Hurley grade, closure method, and excision size did not influence local cure rate. Surgical excision remains a worthy management option for hidradenitis patients with three quarters achieving remission after a single operation. Number of affected regions and location of hidradenitis may play a factor in recurrence.