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Laser and Light Treatments for Hidradenitis Suppurativa
Abbreviations:
hidradenitis suppurativa
(HS)
carbon dioxide
(CO 2 )
neodymium-doped yttrium aluminum garnet
(Nd:YAG)
Hidradenitis Suppurativa Clinical Response
(HiSCR)
Dermatology Life Quality Index
(DLQI)
photodynamic therapy
(PDT)
methyl aminolevulinate
(MAL)
5-aminolevulinic acid
(ALA)
methylene blue
(MB)
Introduction
In additional to traditional topical, medical, and surgical modalities, hidradenitis suppurativa (HS) can also be managed with laser and light-based treatments. These methods have the advantage of targeting affected areas with little to no systemic side effects. They can be used as monotherapy or combined with other treatments. These work by selective photothermolysis to target specific components of the skin and work via several mechanisms, including: debulking lesions, stimulating wound healing, improving scarring, decreasing inflammation, destroying hair follicles, targeting sebaceous glands, and killing bacteria (Fig. 25.1 ). Energy-based treatments are important options in the HS management ladder with different lasers recommended for various stages of severity ( Table 25.1 ). They are often used in conjunction with medical, surgical, and lifestyle modifications as part of comprehensive care for HS patients.
Table 25.1
Summary of Laser and Light-based Treatment Modalities
| Treatment Modality | Level of Evidence | Mechanism of Action | Patient Selection | Pre- and Post- Procedure Care | Complications, Barriers, and Limitations |
|---|---|---|---|---|---|
| Ablative CO 2 | C | Tissue debulking or destruction | Patients with Hurley stage II or III disease with sinus tracts | Intralesional anesthesia pre-procedure, wound is typically left to heal via secondary intention-wound care needed until healing occurs | Patient discomfort, wound care necessary, risk of infection, nerve damage, and recurrence |
| Fractionated CO 2 | C | Improve scarring and stimulate wound healing | Patients with contracture from scarring | Petroleum jelly to the area post-procedure | Patient discomfort |
| Nd:YAG | B | Follicular destruction | All Fitzpatrick skin phototypes and all Hurley stages | None |
|
| Alexandrite | C | Follicular destruction | All Hurley stages | None |
|
| Diode | C | Follicular destruction | All Hurley stages | None |
|
| Topical PDT | C | Tissue debulking or destruction and kill bacteria | Patients with superficial lesions | Incubation period of photosensitizer |
|
| Intralesional PDT | C | Tissue debulking or destruction and kill bacteria | Patients with deep sinus tracts | Incubation period of photosensitizer | Patient discomfort, risk of infection |
| Nonablative Radiofrequency | C | Decrease sebaceous gland activity | All Hurley stages | None | Patient discomfort |
| Ablative Radiofrequency | C | Tissue debulking or destruction | Patients with deep sinus tracts | Intralesional anesthesia pre-procedure | Patient discomfort, risk of infection and burn |
| IPL | C | Follicular destruction and decrease inflammation | All Hurley stages | None | Patient discomfort |
| External Beam Radiation | C | Tissue destruction | Patients who have failed other treatments | None | Patient discomfort, risk of secondary malignancy |
CO 2 , Carbon dioxide; IPL , intense pulsed light; Nd:YAG , neodymium-doped yttrium aluminum garnet laser; PDT , photodynamic therapy.
Carbon Dioxide Laser
The carbon dioxide (CO 2 ) laser (10,600 nm) is used to treat active HS areas as well as for scarring secondary to HS itself or previous HS surgery. Use of CO 2 to vaporize sinus tracts was first described in 1987 by Dalrymple and Monighan, and methods for CO 2 laser excision have evolved from there.
Ablative
The CO 2 laser can be used in the ablative setting to selectively excise HS affected areas while sparing unaffected tissue. It is recommended for patients with Hurley stage II and III HS who have fibrotic sinus tracts. This laser can be used on patients under local anesthesia (with or without tumescent anesthesia) in an outpatient office setting. This results in a decreased risk compared to traditional wide local excision under general anesthesia. Treatment settings include a fluence of 55 W with a 0.2 to 1 mm spot size. The hemostatic properties of the laser allow for excellent visualization of the operative field and accurate assessment of the excised area for residual sinus tracts. The resultant wound is typically left to heal via secondary intention ( Fig. 25.2 ). Thus, appropriate wound care is needed until healing occurs.
Patient satisfaction after CO 2 excision is generally high, with one study reporting 95% of patients having some or great improvement, with 91% recommending the surgery to others. Recurrence rates after CO 2 excision range from 1% to 29%, and infection rates range from 1.6% to 4.9%. Variations in recurrence rates are thought to be due to operator technique, severity and location of disease, and duration of follow-up.
To decrease the risk for recurrence, CO 2 ablation is sometimes used in conjunction with other treatment modalities. In one study, CO 2 laser excision with marsupialization (suturing edges of an abscess) resulted in a recurrence rate of only 1%. Another study found that neodymium-doped yttrium aluminum garnet (Nd:YAG) treatment followed by deroofing sinus tracts with CO 2 laser resulted in lower recurrence than with CO 2 deroofing alone.
Fractionated
CO 2 laser can also be used in a fractionated setting to help improve disease severity and to loosen contractures secondary to scarring from HS or previous HS surgery. The fractionated setting involves creating many small microbeams with normal skin intervening, allowing for more rapid wound healing and less downtime. Several case studies have shown improvement in number and severity of HS lesions, chronic ulceration with granulation tissue, and scar contracture/mobility.
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