Original Article

Experience with different treatment modules in 

hidradenitis suppuritiva: A study of 106 cases

Introduction Patients and Methods Results Discussion References

A. Mandal J. Watson Department of Plastic and Reconstructive Surgery, St. John’s Hospital, Scotland

Correspondence to: A. Mandal, 200 Talbot Road, South Shields, NE34 0RF Email: animandal@hotmail.com 

Background: Hidradenitis suppuritiva, a disease of the apocrine sweat glands, has always been a challenging area to the plastic and reconstructive surgeon. The aetiology is idiopathic and medical treatment offers temporary relief only. Radical surgical excision, therefore, is the mainstay of active management. Aim: To present and evaluate a series of 106 patients of hidradenitis suppuritiva treated in the regional plastic surgery unit of southeast Scotland between January 1990 and December 2000. Patients: Median age at onset was 36 years (range 17-70 years). The patients were predominantly females (88.78%) and heavy smokers (98.1%). Median age before active surgical intervention was six years (range 1-30 years). The patients were divided into a mild group (n=64) and a severe group (n=42). All patients had broad-spectrum antibiotics and multiple incision and drainage procedures before referral from general practitioners, dermatologists or general surgeons. One hundred sites were managed by primary closure (mostly in the ‘mild’ group); 29 resurfaced with split skin grafts and 14 with local, fasciocutaneous or musculocutaneous flaps (mostly in the ‘severe’ group). Median postoperative follow-up period was three years (range 1-7 years). Results: In the ‘primary closure’ series, recurrence rate requiring at least one secondary operation was 69.88%. There was no recurrence, no serious complications and no revision operations in the ‘graft’ and the ‘flap’ series. Conclusion: A high index of suspicion is required before contemplating primary closure in hidradenitis suppuritiva, even in the ‘ mild’ variety. This condition should always be treated aggressively by radical excision of all hair-bearing areas and reconstructed with a graft or a flap

 Keywords: Hidradenitis suppuritiva, treatment, recurrence Surgeon, 1 February 2005, 31-34

INTRODUCTION

Hidradenitis suppuritiva (HS) is a chronic debilitating disease of the apocrine sweat glands, affecting mainly the axillary and the inguinoscrotal regions and rarely the nape of neck, shoulder, inframammary, periumbilical, presternal and retroauricular region. Exact prevalence is unknown; however, a point prevalence of 4.1% and a prevalence estimate of 1:300 has been recorded.¹ Aetiology of the condition is still unclear - follicular occlusion with secondary involvement of apocrine glands is the most probable causative factor.² Shearing forces from obesity and tight clothing, poor hygiene, deodorant and chemical depilation and diabetes mellitus have been postulated as predisposing factors for this condition. Medical treatment in the form of antibiotics, hormonal therapy, retinoids, immunosuppression and radiotherapy can offer temporary relief only.³ Radical surgical excision, therefore, has been formulated as the mainstay of management. This article reviewed different surgical treatment modules for HS and the importance of radical excision even in the ‘mild’ variety.

PATIENTS AND METHODS

The study analysed 143 sites in 106 patients with hidradenitis suppuritiva treated surgically in the regional plastic surgery unit of southeast Scotland over a period of 11 years (January 1990 to December 2000). Demographic details, history of smoking, associated medical disease, sites involved, surface area of the lesion, interval between onset of disease and active surgical intervention, treatment module, grade of surgeon, hospital stay, complication and re-operation rates were retrieved from the case notes. The lesions were divided into two groups - ‘mild’ and ‘severe’. The ‘mild’ group comprised of isolated lesions with limited abscesses. The ‘severe’ group included diffuse multiple abscesses with severe sinus tracts, fibrosis and scarring. The major complications (recurrences) requiring re-operation were analysed in the ‘mild’ and the ‘severe’ variety.

Figure 1: Hidradenitis suppuritivia ‘mild’ group.

Figure 2: Hidradenitis suppuritivia ‘severe’ group. 

Figure 3: Evidence of early recurrence following ‘primary’ closure.

Figure 4: Resurfacing of axilla with ‘local flap’ - no recurrence at three year follow-up.

RESULTS

The median age was 36 years (range 11-70 years). The patients were predominantly females (88.78%) and heavy smokers (98.1%). Diabetes mellitus was the most common associated medical disease (Table 1). The disease primarily involved the axillary region bilaterally followed by unilateral axillary insolvent and the inguinoscrotal region (Table 2). Median surface area was 15cm² (Range 8-80cm). The ‘mild’ group contained 64 patients and the ‘severe’ group 42 patients. Median interval between onset of the disease and active surgical intervention was six years (range 1-30 years). The treatment module consisted of primary closure, mostly in the ‘mild’ variety, and reconstruction with split-thickness graft or flap, mostly in the ‘severe’ variety, operated by all grade of surgeon (Table 3). Median follow-up period was four years (range 2-7 years). Recurrence rate requiring re-operation was 69.88%, occurring exclusively in the ‘primary closure’ series. Minor complications were noted in the ‘graft’ and the ‘flap’ series (five superficial wound infections, two excessive granulations, two patients with restriction of shoulder movement and two dog ears), but no major recurrence was found. Median number of re-operations was three (range 2-6), required only in the ‘primary closure’ series.

DISCUSSION

Hidradenitis suppuritiva continues to be a challenging field for plastic and reconstructive surgeons. Activity of the apocrine glands occurs in puberty and, hence, it is rare to encounter the disease in childhood. Our youngest patient was 11 years of age at the onset of symptoms. The female preponderance was comparable with other studies. However, the association with smoking was excessively high in our study (98.1%), compared with 70-90% documented in other studies.4 Smoking induces altered chemotaxis of polymorphic neutrophils which is possibly an aetiological factor. Smoking cessation is therefore strongly recommended in HS patients. Diabetes mellitus is the commonest medical disease associated with this condition and hence effective diabetes control should be achieved as early as possible.

The optimal surgical management protocol still differ in accordance with the site, extent and nature of the disease and also the experience and preference of the surgeon. Incision and drainage almost invariably leads to recurrence and, therefore, should be reserved for only small single purulent lesion. Primary closure, mostly done in the ‘mild’ variety of the disease, leads to an unacceptable high rate of recurrence and re-operations. Recurrence after operation are attributed to either a compromise in the extent of the excision margin or an unusually wide distribution of apocrine glands.

Large defects have been successfully reconstructed with immediate or delayed split skin grafts, local, fasciocutaneous, pedicled or free flaps.^5,6,8,9 Immediate grafting with the advent of meshing decreases the chance of contamination of the wound. Recently, vacuum-assisted closure has been advocated for stabilising large complex wound (eg axilla), ensuring better graft take.⁷ Our experience with the ‘graft’ and the ‘flap’ series had minor complications only, such as superficial infection, overgranulation and restriction of shoulder movement. All these patients have been managed conservatively without the need for a re-operation.

Definition of ‘ mild’ and ‘severe’ groups is imprecise and, sometimes, there is rapid progression from the ‘mild’ to the ‘severe’ group. The iodine/starch/oxytocin method of excision may be utilised as an adjunct to the eradication of the main bulk of the apocrine glands.⁸ The aim of treatment in HS is to achieve complete cure without local recurrence. Surgeons should have a very high index of suspicion regarding the course of the disease and encouraged to ‘think twice’ before ‘closing once’ even in the ‘mild’ variety. It is better to intervene in the ‘mild’ group with complete resection of the hair-bearing area and resurfacing with a ‘graft’ or a ‘flap’.

Copyright 16 December 2004

REFERENCES

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7. Blackburn JH, Boemil L, Hall WW, Jeffords K, Hauck RM, Banducci DR et al. Negative-pressure dressings as a bolster for skin grafts. Ann Plast Surg 1998; 40: 453-57.

8. Tanaka A, Hatako M, Kuwahara M, Mashiba K, Yurugi S. Experience with surgical treatment of hidradenitis suppuritiva. Ann Plast Surg 2001; 47: 636-42.

9. Elliot D, Kangesu L, Bainbridge C, Venkataramakrishnan V. Reconstruction of the axilla with a posterior arm fasciocutaneous flap. Br J Plast Surg 1992; 45: 101-104