Recurrence Rates Following Reconstruction Strategies After Wide Excision of Hidradenitis Suppurativa: A Systematic Review and Meta-analysis

Presurgical Mapping With Ultra-high Frequency Ultrasound of Hidradenitis Suppurativa Lesions Treated With Wide Local Excision and Secondary Intention Healing

BACKGROUND

Hidradenitis suppurativa (HS) is a challenging chronic inflammatory condition often requiring surgical intervention, such as wide local excision. Preoperative mapping with ultra-high frequency ultrasound (UHFUS) enables detailed assessment of lesion extension, particularly identifying tunnels and fistulas, facilitating surgical planning.

OBJECTIVE

This study aimed to analyze recurrence rates of HS lesions previously mapped with UHFUS and treated with wide excision and secondary intention healing.

MATERIALS AND METHODS

A retrospective single-center study enrolled 40 patients with HS undergoing wide excision surgery after UHFUS mapping. Patients were assessed weekly until complete healing and then every 3 months, evaluating clinical and sonographic signs of relapse and pain using the visual analogue scale.

RESULTS

Results showed a population predominantly composed of women (65%) with a mean age of 39 years and a medium HS-Hurley score of 2.5. Over a 22-month follow-up, only 10% experienced clinical relapse, achieving an 90% total remission rate. Pain scores decreased significantly from Week 0 to Week 4.

CONCLUSION

The study highlights the clinical challenge of HS management, particularly regarding surgical planning and lesion margin definition. The remission rate observed in this study suggests the effectiveness of UHFUS-guided surgical approaches. Future studies should extend observation periods to further validate these findings.

S2k‐Leitlinie zur Therapie der Hidradenitis suppurativa/Acne inversa – Kurzfassung

Die S2k‐Leitlinie der Hidradenitis suppurativa/Acne inversa (HS/AI) soll eine akzeptierte Entscheidungshilfe für die Auswahl/Durchführung einer geeigneten/suffizienten Therapie liefern. Hidradenitis suppurativa/Acne inversa ist eine chronisch‐rezidivierende, entzündliche, potenziell mutilierende Hauterkrankung des terminalen Haartalgdrüsenapparats, mit schmerzhaften, entzündlichen Läsionen in den apokrinen drüsenreichen Körperregionen. Ihre Punktprävalenz in Deutschland ist 0,3%, sie wird mit einer Verspätung von 10,0 ± 9,6 Jahren diagnostiziert. Abnormale Differenzierung der Keratinozyten des Haartalgdrüsenapparats und eine begleitende Entzündung bilden die zentrale pathogenetische Grundlage. Primäre HS/AI‐Läsionen sind entzündliche Knoten, Abszesse und drainierende Tunnel. Rezidive in den letzten 6 Monaten mit mindestens zwei Läsionen an den Prädilektionsstellen verweisen auf eine HS/AI mit einer 97‐prozentigen Genauigkeit. HS/AI‐Patienten leiden an einer deutlichen Einschränkung der Lebensqualität. Zur korrekten Therapieentscheidung sollen Klassifikation und Aktivitätsbewertung mit einem validierten Instrument erfolgen, wie dem International Hidradenitis Suppurativa Severity Scoring System (IHS4). Hidradenitis suppurativa/Acne inversa wird nach der Ausprägung der nachweisbaren Entzündung in zwei Formen eingeteilt: aktive, entzündliche (milde, mittelschwere und schwere nach IHS4) und vorwiegend inaktive, nicht entzündliche (Hurley‐Grad‐I, ‐II und ‐III) HS/AI. Orale Tetrazykline oder eine 5‐tägige intravenöse Therapie mit Clindamycin sind mit der Effektivität von Clindamycin/Rifampicin vergleichbar. Subkutan applizierbares Adalimumab, Secukinumab und Bimekizumab sind für die Therapie der HS/AI zugelassen. Für die vorwiegend nicht entzündliche Erkrankungsform stehen verschiedene operative Verfahren zur Verfügung. Medikamentöse/chirurgische Kombinationen gelten als ganzheitliches Therapieverfahren.

S2k guideline for the treatment of hidradenitis suppurativa / acne inversa - Short version

The S2k guideline on hidradenitis suppurativa/acne inversa (HS/AI) aims to provide an accepted decision aid for the selection/implementation of appropriate/sufficient therapy. HS/AI is a chronic recurrent, inflammatory, potentially mutilating skin disease of the terminal hair follicle-glandular apparatus, with painful, inflammatory lesions in the apocrine gland-rich regions of the body. Its point prevalence in Germany is 0.3%, it is diagnosed with a delay of 10.0 ± 9.6 years. Abnormal differentiation of the keratinocytes of the hair follicle-gland apparatus and accompanying inflammation form the central pathogenetic basis. Primary HS/AI lesions are inflammatory nodules, abscesses and draining tunnels. Recurrences in the last 6 months with at least 2 lesions at the predilection sites point to HS/AI with a 97% accuracy. HS/AI patients suffer from a significant reduction in quality of life. For correct treatment decisions, classification and activity assessment should be done with a validated tool, such as the International Hidradenitis Suppurativa Severity Scoring System (IHS4). HS/AI is classified into two forms according to the degree of detectable inflammation: active, inflammatory (mild, moderate, and severe according to IHS4) and predominantly inactive, non-inflammatory (Hurley grade I, II and III) HS/AI. Oral tetracyclines or 5-day intravenous therapy with clindamycin are equal to the effectiveness of clindamycin/rifampicin. Subcutaneously administered adalimumab, secukinumab and bimekizumab are approved for the therapy of HS/AI. Various surgical procedures are available for the predominantly non-inflammatory disease form. Drug/surgical combinations are considered a holistic therapy method.

What should a surgeon know about hidradenitis suppurativa?

Otherwise known as Verneuil's disease, hidradenitis suppurative (HS) is a severe dermatosis of heterogeneous appearance affecting 1% of the population. Its pathophysiology is multifactorial, involving genetic predisposition, inflammatory disorder and environmental elements. Its diagnosis is based on the association of three clinical characteristics: characteristic lesions, typical localizations, and the chronic and recurrent nature of the lesions. Given its diversified aspects, diagnosis can be difficult to achieve. As its manifestations often include abscesses, it is important for the surgeon to know how to detect this pathology. The development of biologics has improved treatment of this disease, treatment that necessitates a multidisciplinary medical and surgical approach involving dermatologists and proctologists as well as surgeons. The objective of this report is to synthesize what a surgeon will need to know so as effectively treat HS patients.

Efficacy of procedural treatments for pediatric hidradenitis suppurativa: A systematic review

Hidradenitis suppurativa (HS) is a painful, inflammatory skin disease that has historically been understudied in the pediatric population. Procedural interventions, such as surgical excisions, skin grafts, and lasers, are important for comprehensive HS disease management. However, there is a lack of data on procedural treatments for HS in pediatric patients. The purpose of this study was to conduct a systematic review of the literature on the efficacy and safety of procedural treatments for HS in pediatric patients. In April 2022, MEDLINE and EMBASE databases were searched for articles on the efficacy of procedural treatments for HS in patients <18 years of age. Two independent reviewers extracted data from relevant studies. From 1974 to 2021, 23 articles with 81 patients were identified. Patients' Hurley stages included stage I (9.1%, 1/11), II (36.4%, 4/11), and III (54.5%, 6/11). The most extensively studied procedural interventions include negative pressure wound therapy (n = 30), surgical excision with skin graft/flap (n = 19), and endoscopic electrode or laser treatment (n = 11). In all, promising response rates for procedural management strategies were observed in the literature but the findings were largely based on case reports/series. Randomized controlled trials (RCTs), especially those geared toward minimally invasive procedural treatments, are needed to help guide clinicians on the most efficacious treatment modalities for pediatric patients with HS.

Surgical Procedural Definitions for Hidradenitis Suppurativa Developed by Expert Delphi Consensus

Importance

Various surgical approaches for hidradenitis suppurativa (HS) have been described in the literature, but the nomenclature is inconsistent. Excisions have been described as wide, local, radical, and regional with variable descriptions of margins. Deroofing procedures have been described with various approaches though descriptions of the approach are generally more uniform. No international consensus has been formed to globally standardize terminology for HS surgical procedures. Lack of such agreement may contribute to misunderstanding or misclassification in HS procedural research studies and impair clear communication among clinicians or between clinicians and patients.

Objective

To create a set of standard definitions for HS surgical procedures.

Design, Setting, and Participants

This consensus agreement study was conducted from January to May 2021 using the modified Delphi consensus method to reach agreement among a group of international HS experts regarding standardized definitions for an initial set of HS surgical terms, including "incision and drainage," "deroofing/unroofing," "excision," "lesional excision," and "regional excision," ultimately expanded to 10 terms. Provisional definitions were drafted based on existing literature and discussion among an expert 8-member steering committee. Online surveys were disseminated to members of the HS Foundation, direct contacts of the expert panel, and the HSPlace listserv to reach physicians with considerable experience with HS surgery. Consensus was defined as greater than 70% agreement to accept a definition.

Results

In the first and second modified Delphi round, 50 and 33 experts participated, respectively. Ten surgical procedural terms and definitions reached consensus with greater than 80% agreement. Overall, the term "local" excision was abandoned and replaced with the descriptors "lesional" or "regional" excision. Of note, "regional" replaced the terms "wide" and "radical" excision. Furthermore, modifiers such as "partial" vs "complete" should also be included when describing surgical procedures. A combination of these terms helped formulate the final glossary of HS surgical procedural definitions.

Conclusion and Relevance

An international group of HS experts agreed on a set of definitions describing surgical procedures frequently used by clinicians and in the literature. The standardization and application of such definitions are vital to allow for accurate communication, reporting consistency, and uniform data collection and study design in the future.

Surgical Management of Hidradenitis Suppurativa: Factors Associated with Postoperative Complications and Disease Recurrence

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disorder. Treatment of HS remains challenging, and surgical procedures commonly follow attempts of conservative therapy. To date, a consensus regarding the optimal surgical technique has not been reached, and the implications of conservative therapy on future surgical outcomes have yet to be studied.

METHODS

A retrospective cohort study of 65 patients surgically treated for HS at a tertiary care center was conducted. Patients' medical records were screened for demographical, clinical, and surgical characteristics. Statistical analysis was conducted to determine associations with postoperative complications and disease recurrence.

RESULTS

Fifty patients (75.8%) were treated with systemic antibiotics before opting for surgical resection. Previous treatment with systemic rifampicin was associated with higher rates of postoperative complications (P = 0.029); however, systemic cephalexin and topical clindamycin were associated with a lower rate of complications (P = 0.007 and 0.040, accordingly). Medical history of smoking and surgical management with split-thickness skin grafts were associated with higher rates of postoperative complications (P = 0.012 and 0.014, accordingly). Patients with a greater number of lesions, and those treated with split-thickness skin graft, had higher rates of disease recurrence (P = 0.0018 and 0.003, accordingly).In a multivariate analysis a greater number of lesions (P = 0.0498) and the use of autologous split-thickness skin graft (P = 0.022) were independently associated with higher rates of disease recurrence.

CONCLUSIONS

Previous conservative medical therapy bears the potential to modulate postoperative outcomes in HS patients, and should be taken into consideration. Despite reports of reliable results with split-thickness skin grafts, we found them to be associated with increased rates of diseases recurrence and postoperative complications.

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.

Outcomes and Reliability of Perforator Flaps in the Reconstruction of Hidradenitis Suppurativa Defects: A Systemic Review and Meta-Analysis

INTRODUCTION

Hidradenitis suppurativa (HS) is a common and debilitating disease, in which the only effective treatment involves a wide excision of the affected skin. Secondary wound healing and skin grafting are two well-known options for managing these defects, but perforator flaps provide a new therapeutic alternative by ensuring reconstructions of large defects, reducing donor site morbidity, and enhancing functional recovery. The aim of this study was to achieve a systematic review of perforator flaps use in HS.

PATIENTS AND METHODS

PubMed and Cochrane databases were searched from 1989 to 2021. The PRISMA statement was used in the study selection process and the review was registered on PROSPERO. Furthermore, patient characteristics, operative technique, complications, and recurrences were searched.

RESULTS

Thirty-six articles were selected including 286 patients and 387 flaps. Axillary localization was mostly represented (83.2%). Direct donor site closure was achieved in 99.1% of cases. In total, 15.1% of the flaps presented at least one of the following complications: wound dehiscence (5.5%), partial necrosis (2.9%), hematoma or seroma (2.1%), infection (2.1%), venous congestion (1.8%), and nerve injury (0.3%). Two cases of total necrosis were recorded. Recurrence of the disease was observed in 2.7% of the defects.

CONCLUSIONS

Pedicled perforator flaps are a reliable and reproducible technique in the reconstruction of HS defects. They are associated with a low recurrence rate while ensuring an effective reconstruction with reduced morbidity and faster recovery compared to the techniques classically used in this indication.

The Value of Negative-Pressure Wound Therapy and Flap Surgery in Hidradenitis Suppurativa – A Single Center Analysis of Different Treatment Options

Background

Hidradenitis suppurativa is manifested by painful abscesses and scarring of sweat glands. Axillary, inguinal and genital regions are mostly affected. Multiple options exist in the treatment of hidradenitis suppurativa. The aim of this retrospective, mono-center cohort study was to analyze the outcome of different treatment methods after radical excision of hidradenitis suppurativa.

Methods

We retrospectively evaluated the treatment strategy and recurrence rate of hidradenitis suppurativa. We included all eligible patients of legal age between February 2003 and October 2021, with the diagnosis of Hidradenitis suppurativa and the necessity for surgical treatment. All patients with surgical treatment and direct wound closure by suture were excluded. Bacterial load and flora were analyzed for primary and secondary reconstruction in combination with negative-pressure wound therapy. Patient data were analyzed for recurrence rate and remission time according to different reconstructive techniques.

Results

In 44 affected anatomical sites (n = 23 patients) we treated 15 patients with negative-pressure wound therapy. Bacterial load and flora were lower in the last wound swab of patients with multi-surgical procedures (22 localizations) compared to the first wound swab independent of the use of negative-pressure wound therapy.

Wound closure, independent of a direct and multi-stage procedure was achieved by local fasciocutaneous flaps (n = 12), secondary intention healing (n = 7), secondary intention healing with buried chip skin grafts (n = 10), or split-thickness skin grafts (n = 15). Radical excision combined with split-thickness skin grafts showed the lowest recurrence rate in the follow-up (16%; n = 4).

Conclusion

Radical excision of hidradenitis suppurativa as gold standard for surgical treatment combined with negative-pressure wound therapy as multi-stage procedures ultimately reduced bacterial load and flora in our study. The use of split-thickness skin grafts showed the lowest recurrence rate.

New perspectives on the treatment of hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease characterized by the presence of painful nodules, abscesses, chronically draining fistulas, and scarring in apocrine gland-bearing areas of the body. The exact pathogenesis of HS is not yet well understood, but there is a consensus in considering HS a multifactorial disease with a genetic predisposition, an inflammatory dysregulation, and an influence of environmental modifying factors. Therapeutic approach of HS is challenging due to the wide clinical manifestations of the disease and the complex pathogenesis. This review describes evidence for effectiveness of current and emerging HS therapies. Topical therapy, systemic treatments, biological agents, surgery, and light therapy have been used for HS with variable results. Adalimumab is the only US Food and Drug Administration (FDA) approved biologic agent for moderate-to-severe HS, but new therapeutic options are being studied, targeting different specific cytokines involved in HS pathogenesis. Comparing treatment outcomes between therapies is difficult due to the lack of randomized controlled trials. Treatment strategy should be selected in concordance to disease severity and requires combination of treatments in most cases.