5 Considerations for the Surgical Management of Hidradenitis Suppurativa

When the young female patient first met with the surgeon, she had already been battling hidradenitis suppurativa for two years. The auto-inflammatory disease, also known as acne inversa, that causes inflamed and painful skin lesions presented itself in her groin, axilla and intermammary region—the latter causing significant distress.

The patient had already tried several treatments to no avail—topical clindamycin, oral minocycline, clindamycin, combination ciprofloxacin and metronidazole, spironolactone and oral contraceptive pills.

She underwent surgery to excise the subcutaneous sinus tracts in her intermammary region, followed by a flap procedure for wound closure. With the exception of one nodule that recurred 16 months later (and was quickly addressed with a follow-up deroofing procedure and use of adalimumab), the patient had complete healing. Her surgeon credits the successful outcome to a combination of surgery and medical management early in the course of her condition.

As in this case, surgical intervention is not usually the first choice in management of hidradenitis suppurativa. Surgery is typically reserved for those whose symptoms cannot be controlled by pharmacologic care alone.

Hidradenitis Suppurativa Surgery

There is also no consensus on surgical management of acne inversa because treatment is based on disease severity, comorbidities and other individual characteristics. Surgery alone does not alter the course of the disease therefore it’s important to understand the tradeoffs between the extent of excision, surgical morbidity and reducing the risk of future lesions. For example:

• • Incision and drainage may offer short-term pain relief, but recurrence is almost certain.
  • Unroofing the subcutaneous sinus tract, exploring and treating the side passages and leaving the wound to heal may be performed on individual lesions (local unroofing) or on multiple lesions in one area (extensive unroofing).
  • Excision is often recommended for patients with more severe cases. Local excision is removing individual lesions plus a margin of healthy tissue, while wide excision is removing all lesions in one area, along with skin beyond the clinical borders of disease activity.

Evidence-Based Guidelines in the Management of Hidradenitis Suppurativa

In 2019, the United States and Canadian Hidradenitis Suppurativa Foundations published the American Clinical Management Guidelines for Hidradenitis Suppurativa in The Journal of the American Academy of Dermatology.

The evidence-based guidelines were designed to support healthcare practitioners in optimal management strategies for hidradenitis suppurativa, including diagnostic testing, comorbidity screening and complementary and procedural treatment options.

Diagnostic testing includes biofilm, while acne inversa comorbidities include smoking, obesity, diabetes, metabolic syndrome, depression/anxiety, follicular occlusion tetrad, and squamous cell carcinoma.

As part of the guidelines’ recommendations for hidradenitis suppurativa surgery, the following findings were presented for consideration:

• • There was a 4% overall recurrence rate in surgically treated patients, with younger age and operation at multiple sites associated with an increased risk, in one study of 509 patients.
  • When hidradenitis suppurativa affects perianal, vulvar and inferior breast locations, there have been higher recurrence rates in published studies.
  • Incision and drainage procedures have been associated with recurrence rates reaching upwards of 100%, although such an intervention may be worthwhile to provide relief when other methods are not possible.
  • Despite the high recurrence rates, incision and drainage procedures may help reduce the inflammation and size of the affected tissue, allowing for a smaller definitive procedure in the future.
  • Wide local excision can result in a disease-free state where the excision was performed, but it may also lead to large tissue defects that require reconstructive surgery.

The American Clinical Management Guidelines for Hidradenitis Suppurativa guidelines also review some of the non-surgical treatment options for acne inversa including quitting smoking, losing weight, wound care, use of dietary supplements and wearing loose clothing.

Ultimately, if left untreated, or if treatments fails, hidradenitis suppurativa is associated with poor quality of life for patients, including pain, itch and discomfort, shame, isolation, worries about appearance, fear of body odor, and troubles with sexuality and depression. It can be embarrassing and often affects patients’ work and intimate relationships and has been cited as one of most distressing dermatological conditions.

A study at Trinity College Dublin showed that patients with hidradenitis suppurativa were significantly more impacted by their condition, according to the Dermatology Life Quality Index, compared to patients with psoriasis. Another study comparing patients with moderate to severe HS to those with moderate to severe plaque psoriasis showed that the HS patients experienced greater pain, lower work productivity and reduced health care quality of life.

Hidradenitis suppurativa patients scored 12.2 (large effect on QOL) vs. psoriasis patients’ score of 9.9 (moderate effect) when measured based on symptoms  The DLQI measures quality of life based on symptoms, daily activities, leisure, work/school, personal relationships and quality of treatment.

Hidradenitis suppurativa is a difficult condition to treat, and the best approach is often achieved through a multidisciplinary care team approach that involves surgeons as well as dermatologists, primary care physicians, wound care specialists and pain management specialists, among others.

Read 7 interesting takeaways from a comparison of hidradenitis suppurativa treatment guidelines across the globe.