Office-Based Excision for Hidradenitis Suppurativa: A Surgeon’s Decades-Long Experience

Introduction

Every patient with hidradenitis suppurativa (HS) has a unique story to tell. All too often this story is a long one that includes numerous treatments, frustration, pain, and social embarrassment. By the time I see the patient, he or she has a skeptical feeling toward–if not frank distrust of–physicians. Fortunately for most patients, HS can be regionally cured if an adequate surgical excision is performed. This chapter will explore the literature regarding surgery for HS and my own perspective after personally performing more than 200 HS operative procedures, mostly in the past 10 years at the University of California, Los Angeles (UCLA).

I was fortunate to train in dermatology at the University of Pennsylvania under Drs. Walter Shelley and Harry Hurley. Both of these physicians had a great interest in apocrine gland diseases and sparked my interest in HS. It was Dr. Hurley who first showed me how to unroof HS (in those days we called it “marsupialization”). Early in my career, I subsequently wrote about this technique and demonstrated it to plastic surgeons in the operating room.

Over the years, my career has been mainly devoted to Mohs micrographic surgery. As my surgical ability increased, I began to operate on more extensive and difficult HS cases. This interest led to the development of an HS Clinic at UCLA. Mohs micrographic surgery and HS excisions have a lot in common. Both techniques are used to spare normal tissue, try to fully extirpate the disease process, involve management of healing wounds, and are sensitive to the complexities of histologic examination. We now examine frozen sections on all HS patients—not to examine for excision margins, but rather to gain a new perspective on HS pathology by careful orientation of the excised specimens to visualize the relationship between the skin, sinus tracts, and inflammation. My experiences and clinical pearls regarding surgical excisions in HS patients are shared in this chapter.

Historical Perspective

Although HS was first described in the 19th century by Velpeau and Verneuil, adequate treatment was not available until the mid-20th century. Initially, hot packs, incision and drainage, or even x-rays, were recommended. It should be noted that x-rays were also recommended in HS for epilation, similar to laser hair removal today. Around 1950, general surgeons and plastic surgeons began recommending large excisions that were repaired with split thickness skin grafts. Slightly later, in the 1960s and 1970s, excision with skin flaps was advised. Since then, numerous skin flap techniques have been described for both the axilla and inguinal areas. More recently, microvascular free flaps have also been reported. Along the way, healing by granulation was mentioned, especially in the axilla, groin, buttock, and perianal areas.

Dermatologists working independently from surgeons came up with the idea of unroofing HS lesions. Although this technique was first described in 1959 by J. Fred Mullins, it was largely overlooked until recently, when it was again popularized by Bill Danby. However, this technique is useful mainly on small superficial HS lesions.

Surgical Approaches

There are several surgical approaches that can be used to excise HS, ranging from conservative to radical. Almost all these procedures can be performed safely and conveniently under local anesthesia in an office setting with the exception of large flaps or in patients with extensive HS. Since each patient presents with a unique problem, the choice of surgical treatment depends upon the disease stage and when the patient appears. Incision and drainage, deroofing, and lasers are discussed in detail in other chapters (see below).