Case Competition 2023 Case 18 Surgical management of hidradenitis suppurativa
Authors: Ema Šutáková med. stud., Dominika Miklišová med. stud., Mirka Verbat med. stud., Julia Bartková, MD
A 59 year old female presented with chronic hidradenitis suppurativa in both axillae, lower quadrants of breasts, inframammary folds and both groins. She had a medical history of essential hypertension treated by angiotensin II receptor antagonists, hypothyroidism on thyroid hormone replacement therapy and type II diabetes treated by oral antidiabetic drugs. She underwent a hysterectomy in 2007. Hidradenitis suppurativa first occured in 2020. Considering risk factors, the patient denies smoking, but presents obesity as a significant risk factor with body mass index 33,6. She had negative family history of hidradenitis suppurativa. Female gender is another risk factor to be considered as this disease occurs more frequently in female with a female:male ratio 3:1. The overall prevalence of hidradenitis suppurativa was found to range between 0.7% and 1.2% in the European-US population. (1,2)
Before and after
The diagnosis of hidradenitis suppurativa is generally made clinically. The patient presented with characteristic chronic inflammatory skin lesions including deep-seated nodules with discharging abscesses and fibrotic scarring in the axillae, upper lateral quadrants of breasts, inframammary folds and groins.
With limited data available on randomised clinical trials on the treatment of hidradenitis suppurativa, a multidisciplinary approach including mainly dermatologist and plastic surgeon is key to prompt optimal disease control. A personalised treatment plan is usually constructed by dermatologist. An assessment by a plastic surgeon is proposed for selected patients with Hurley stage 1 and all patients with Hurley stages 2 and 3. The most commonly proposed surgical approach consists of wide excision of lesions and reconstruction with dermoepidermal grafts when primary closure is impossible. For obese patients (BMI ≥ 30 mg/m2), a consultation with a physician who specializes in nutrition is proposed. For patients with class 2 obesity (BMI ≥ 35 mg/m2), a bariatric intervention with a bariatric surgeon can be discussed. Female patients with clinical signs of hyperandrogenism or hormone serum abnormalities are referred to an endocrinologist. (3) Patients are advised to control their weight and refrain from smoking. The early stages can be managed with topical or systemic antibiotics or immunosupresive treatment, but the advanced stages mostly require surgical intervention. (4) Stage I is managed with topical antibiotic therapy, e.g. Clindamycin 10mg/ml twice a day for three months has been reported to reduce the number of abscesses, nodules and pustules. When topical treatment is insufficient, oral antibiotics are commonly used or a combination of topical and oral antibiotics. (5) Anti-androgen drugs are sometimes used in women, though the patient did not undergo anti-androgen treatment. Systemic immunosuppressives are recommended to patients with high stage disease with abscesses, extensive scaring and cysts. Adalimumab, an anti-TNFα monoclonal antibody sold under the brand name Humira has been used with good results. (6) Surgery is used in patients with stage III or stage II in those who have extensive scarring and are non-responsive to treatment mentioned above. Severe forms of hidradenitis suppurativa can often lead to severely mutilating procedures. Incision and drainage of acute lesions provide a rapid relief of the symptoms, but recurrence rates are close to 100%. (6) In patients with less extensive disease, local excision of sinus tracts, cysts and abscesses is usually sufficient and can be left open to heal by secondary intention. The patient was treated by antibiotic therapy for 2 years after the diagnosis with unsatisfactory response, so the decision to start biological therapy was made. She has been undergoing treatment by adalimumab inj. s.c. once in 2 weeks for about 8 months and she was recommended surgical treatment. In this case, more extensive procedure was required involving wide excision of skin in the affected areas.
Step 1: Photo before surgery
Multiple interconnected sinus tracts and fibrotic scarring in left axilla and upper lateral quadrant of left breast.
Step 2: Pre-operative planning
Marking the areas of planned excision.
Step 3: Excision – left side
Excision of the affected areas under general anesthesia in both axillae and upper lateral quadrant of right breast. Before the preparation of the operating field started, a skin swab had been performed and sent for microbiological examination with further negative result. After that preparation of the surgical field started with disinfection by povidone-iodine topical disinfectant and draping the surgical field to maintain sterility. We then proceeded with the excision of the areas. Electrocoagulation was used for hemostasis.
Step 4: Excision – right side
Excision of the affected areas on the right side.
Step 5: Wound closure – left side
In the first intention the defects in the axillae were partially closed by deep dermal suture and simple interrupted epidermal suture. The rest of the wound bed was temporarily covered by sterile polyethylene mesh with polyurethane foam dressing to prepare the wound surface for further dermoepidermal graft autotransplantation. Skin stapler was used for fixation of the dressing. The defects of the upper lateral quadrants of the breasts were closed by deep dermal suture and simple interrupted epidermal suture. The patient had systemic antibiotic profylaxis to decrease the risk of infection of the wound. In the second intention, about 10 days after the procedure, the wound was covered by autologous dermoepidermal skin graft meshed 1:1,5. The donor site of the autotransplant was the left inner thigh. The graft was fixed by skin stapler.
Step 6: Wound closure – right side
Dressing placement on the right side.
Step 7: Follow-up (4 months)
The patient was seen 4 months post-op in the outpatient clinic for a follow-up, the wound was without any signs of infection, skin graft was vital, contracture was not present. The patient denied any signs of discomfort or pain in the areas or limitations in range of motion. Second follow-up was made by phone-call 18 months post-op, the patient presents no contracture of the skin grafts and is very satisfied with the esthetic result. She has no recurrence of hidradenitis suppurativa in the axillae. There is a persistent difference in color of the graft and the surrounding skin, but the patient does not see it as an issue.
The patient continues the treatment of hidradenitis suppurativa by adalimumab and she has regular follow-up visits with a dermatologist.
- The patient was very satisfied with the esthetic result and came back to the clinic six months after the operation to have her inguinal lesions treated surgically as well, in this case the wound was closed by simple suture. She is planning to have her inframammary folds lesions treated surgically in the future as well.
- Management of hidradenitis suppurativa can often be unsatisfactory and challenging due to the chronic nature of the disease and its adverse impact on the quality of life. Hidradenitis suppurativa interferes with many aspects of everyday life, including work, sexual health and interpersonal interactions, mainly due to pain, recurrent suppuration, and odour. (4) The prevalence of depression in patients with hidradenitis suppurativa is 16.9% while the prevalence of anxiety is 4.9%. (7) Surgical treatment can significantly improve the quality of life of the patients. However, the recurrence rate is reportedly high even after wide surgical excision. It is still unclear which reconstruction method provides the lowest recurrence rate. (8)
- Mind the difficult fixation of the dermoepidermal grafts in the axillae when planning the procedure. In general skin grafts may be complicated by graft healing problems and donor site morbidity and they may result in contractures, noticeable differences in color and texture with the surrounding skin and extensive scarring. (9) It might be necessary to release the graft contractures surgically if the patient presents with pain or discomfort, deformity or limitations in range of motion.
- Jfri A, Nassim D, O’Brien E, Gulliver W, Nikolakis G, Zouboulis CC. Prevalence of Hidradenitis Suppurativa: A Systematic Review and Meta-regression Analysis. JAMA Dermatol. 2021;157(8):924-931. doi:10.1001/jamadermatol.2021.1677
- Amat-Samaranch V, Agut-Busquet E, Vilarrasa E, Puig L. New perspectives on the treatment of hidradenitis suppurativa. Ther Adv Chronic Dis. 2021;12:20406223211055920. Published 2021 Nov 23. doi:10.1177/20406223211055920
- Timila Touhouche A, Chaput B, Marie Rouquet R, et al. Integrated multidisciplinary approach to hidradenitis suppurativa in clinical practice,. Int J Womens Dermatol. 2020;6(3):164-168. Published 2020 Feb 22. doi:10.1016/j.ijwd.2020.02.006
- Shukla R, Karagaiah P, Patil A, et al. Surgical Treatment in Hidradenitis Suppurativa. J Clin Med. 2022;11(9):2311. Published 2022 Apr 21. doi:10.3390/jcm11092311
- Mi N. Hidradenitis suppurativa – a case report. J West Afr Coll Surg. 2011;1(4):60-69.
- Ovadja ZN, Zugaj M, Jacobs W, van der Horst CMAM, Lapid O. Recurrence Rates Following Reconstruction Strategies After Wide Excision of Hidradenitis Suppurativa: A Systematic Review and Meta-analysis. Dermatol Surg. 2021;47(4):e106-e110. doi:10.1097/DSS.0000000000002815
- Machado MO, Stergiopoulos V, Maes M, et al. Depression and Anxiety in Adults With Hidradenitis Suppurativa: A Systematic Review and Meta-analysis. JAMA Dermatol. 2019;155(8):939-945. doi:10.1001/jamadermatol.2019.0759
- Sugio Y, Tomita K, Hosokawa K. Reconstruction after Excision of Hidradenitis Suppurativa: Are Skin Grafts Better than Flaps?. Plast Reconstr Surg Glob Open. 2016;4(11):e1128. Published 2016 Nov 10. doi:10.1097/GOX.0000000000001128
- Manfredini M, Garbarino F, Bigi L, Pellacani G, Magnoni C. Hidradenitis Suppurativa: Surgical and Postsurgical Management. Skin Appendage Disord. 2020;6(4):195-201. doi:10.1159/000507297