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Hidradenitis Suppurativa—Other Procedural Treatments
Introduction
The treatments for hidradenitis suppurativa (HS) can generally be divided into those with pharmacologic focus, and those that are procedural. For milder Hurley stage I disease, management is usually medication-focused, and designed to control or prevent the inflammatory events. For more severe disease, the physical signs of scars, acute or persistent abscesses, nodules, and sinus tracts may be accompanied by symptoms of ongoing or acute pain, drainage, itching, and odor. It is therefore in the setting of incomplete control of either signs or symptoms of the disease that procedural management becomes an important option.
Procedural Options
Procedures may be categorized by their applications in (1) the acute manifestations of the disease, or (2) for chronic, persistent disease. When treating acute lesions, it is helpful to note that the intensity of inflammation alters the pH of the perifollicular dermis, leading to blunting of the effectiveness of local anesthetics. It is, therefore necessary to often administer a “ring” of anesthesia outside the inflamed lesion. Additionally, the presence of scarring, multilocular abscesses, or sinus tracts may limit anesthetic dispersal, and thereby reduce the effectiveness of anesthetic agents.
Treatment of the Acute Lesion
Management of the acute lesion can be pharmacologic, destructive, or ablative in nature.
Acute flares may be initially managed with medications, with treatment options including oral or intralesional anti-inflammatory agents, antibiotics with anti-inflammatory properties, or analgesics. The question of superinfection with bacterial pathogens should be considered; this may be suggested by the presence of prominent erythema and warmth surrounding the primary process, and/or increasing malodor. Culture, and treatment with appropriate antibacterial agents, may be warranted.
Procedural treatments may be considered for those lesions that might be uncontrolled with pharmacologic agents alone. Large abscesses, or lesions comprised of sinus tracts and/or scars, are especially not likely to be successfully managed with only pharmacologic therapy. Intralesional corticosteroids may help to reduce acute pain in the short term, but are often ineffective in acute, larger cavitary lesions.
Unroofing/Deroofing, Incision, and Drainage
Unroofing and incision and drainage (I&D) are most beneficial for the solitary abscess or tract; they are less effective in the more chronic lesions where there may be scarring, nodules, and sinus tracts. For management of larger, acute lesions, a procedure to facilitate release of the purulent material within an abscess is often associated with almost-immediate symptom improvement. I&D is usually effective in reducing acute pain, but is associated with significant risk of recurrence. Unroofing, also known as deroofing, is generally more effective than I&D, and results in less risk of recurrent abscess formation. It may be helpful especially where there is a single cavitary abscess. Unroofing/deroofing and I&D are discussed in detail in Chapter 22, Chapter 23, Chapter 24 .
Other options for procedural treatment of HS lesions may be broadly categorized into two general choices: (1) destruction/ablation, or (2) removal. Destruction may be defined as the ablation of the inflammatory process, without physically removing tissue. Alternatively, physical removal of affected skin may be employed, with various options for wound-healing. Local anesthesia is appropriate for all these procedures.
Destruction
Destruction of the acute lesion attempts to produce controlled injury to the tissue, followed by healing with lesion resolution. Multiple approaches have been evaluated, including carbon dioxide laser ablation, radiotherapy, peeling agents, cryoinsufflation, and neurotoxins. Each of these will be reviewed, with strength of recommendations as noted in Table 26.1.
Table 26-1
Procedural Modalities for Management of Acute and Chronic Lesions of Hidradenitis Suppurativa: Literature Review, to Determine Strength of Recommendation, Level of Evidence
| Modality | Strength of Recommendation | Level of Evidence |
|---|---|---|
| Incision & Drainage | C | III |
| Unroofing/Deroofing | B | II |
| Cryosurgery | C | III |
| Cryoinsufflation | E | III |
| Peeling Agents | B | II |
| Neurotoxins | D | III |
| CO 2 Laser Excision | C | II |
| CO 2 Laser ablation | C | II |
| Staged CO 2 Laser Excision/Marsupialization | C | II |
| Radiation | C | II |
Treatment of the Chronic Lesions
Carbon Dioxide (CO 2 ) Laser Ablation
Laser ablation has the same goals as that noted with cryo- or electro- surgical approaches; that is, the destruction of the inflammatory process. Although potentially able to treat acute lesions, the treatment is largely reserved for Hurley stage II to III patients with chronic disease.
The principle of such treatment relies on the laser energy absorption by the moisture of skin, with the resultant thermal effects causing destruction of the targeted lesion. The technique is usually performed using local anesthesia. Patients may continue pharmacologic therapy without interruption.
In 1987, Darlymple and Monaghan described the use of CO 2 laser to ablate HS lesions in six patients with a variety of sites. Subsequently, in 1991, Sherman and Reid reported using the CO 2 laser to treat large areas of the vulva in 11 patients, employing a combination of laser ablation and focal areas of laser excision.
The technique is performed as follows. The visible and palpable margins of the lesion to be treated are identified. The laser parameters are set for scanning/defocused mode, to make repeated passes over the HS lesion. Treatment is continued until the delivery has reached the pre-set depth and margins of the affected lesion(s). All elements of HS, including abscesses, nodules, scars and sinus tracts may be treated. Healing takes place by secondary intention. The presence of thickened scars and/or extensive epithelial-lined sinus tracts may blunt the effects of the scanning laser.
The technique has been associated with good patient acceptance, acceptable qualities of healing, and improved comfort of treated areas. However, recurrence rates approach 30%. A potential side effect is a post-operative flare of other involved areas. Laser treatments for HS, including Nd:YAG, are further discussed in chapter 25 .
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