HIDRADENITIS SUPPURATIVA
HIDRADENITIS SUPPURATIVA: A Case Series of Eight
PatientsHidradenitis suppurativa gluteiMomcilo Stosic, Igor
StojanovicThe Department of Surgery, Vranje
Prim Dr sci Momilo D. Stoi, Vojvode Miia 17, 17500 Vranje,
[email protected]/hirurskiugaoSummaryIntroduction
Hidradenitis suppurativa is a persistent, inflammatory and
recurrent disease of the hair follicles which, in time, results in
ugly scars. Earlier it was thought that the basis of the diseases
is inflammation and obstruction of channel of sweat glands.Case
Series: This paper presents the cases of 8 patients operated on in
the past 3 years. We point to a possibility of an oversight in
making the diagnosis, as well as an under-estimate in the
treatment. Together with surgical methods, we also present other
therapeutic possibilities from the existing literature. This is
retrospective analysis of the surgical findings. The treatment was
multidisciplinary buth the surgical excision has been the only
option which provides a healing without recidives so far. In our
series the excision can be done to the fascia or to leave a thin
layer of adipose tissue. Reconstruction can be done by healing per
secundam, by autologous skin or artificial graft, or by narrowing
of the wound with a skin portion. Our results acquared by stage,
secondary stitches and rotation portions were satisfying.
Conclusion In advanced disease only a surgery can lead to healing.
We performed late surgery because the patients occurred in the late
stages by Hurlayu. The operative management is a wide excision in
all our patients. Reconstruction was performed: in 3 patients with
rotation flap, in 4 patients the wound healing per secundam and in
one with primary suture. Our patients did not suffer recidives of
the primary disease. The disease was combined in one cases with
perianal fistula.Keywords: hidradenitis suppurativa, hair
follicles, sweat gland, surgical excision.
IntroductionWhen hidradenitis suppurativa (HS) is mentioned,
most surgeons think that they know what, when and how to treat. Is
that really true? The fact is that there are too many cases when
the diagnosis was oversighted [1]. Actually, it is a common
dermatological and surgical problem.Hidradenitis suppurativa is a
chronic, recidivous, inflammatory and painful process in the
follicles of hair and near sweat gland. It is characterized by a
thickening of the affected skin together with knots and sinuses and
development of ugly scars [2]. Topologically, it primarily affects
the skin of the folds i.e. the skin of the armpits, groin, genitals
and perianal region. The disease was precisely defined on the
Second International HS Research symposium in San Francisco in
March, 2009. [3]. The synonyms for the disease are acnae inverse,
Verneuils disease and follicular hyperkeratosis [4].The objective
of the study was to show a little series of patients with pictures
and definitive results of the surgical procedure. We point to a
possibility of an oversight in making the diagnosis, as well as an
under-estimate in the treatment. Together with surgical methods, we
also present other therapeutic possibilities from the existing
literature.Case reports:In the three-year period between 2011 and
2013, 8 patients diagnosed with hidradenitis suppurativa were
operated on in the regional Department of Surgery. All the patients
were male. The localization in 7 of the patients was the perianal
and gluteal region. One patient had changes both in the inguinum
and pubis. The age of the patients ranged from 30 to 73 years, the
average being 42 years. Through a retrospective analysis of the
surgical findings of all 8 patients, together with an interview
(after median age of 1 year, and with 2 of them after a shorter
period of time), we gathered the data about the treatment methods
applied before the surgery, about the length of the treatment,
then, the quality of life before the surgery, especially related to
the disease, and, finally, the level of satisfaction after the
surgery, both in the functional and aesthetic aspect. Other
references were obtained by using the PUBMED and MEDLINE services.
The diagnosis was made in all 8 patients by inspection (Figure 1
and 2). We had a differential-diagnostic dilemma about 2 patients
whether a perianal fistula was present, which proved true in one
case intraoperatively. The average length of the treatment before
the surgery was over 15 years. They were treated with antibiotics,
disinfectants and occasional incisions. Before the arrival to the
Department of Surgery, just one patients had an accurately made
diagnosis. Two of them were treated with the diagnosis of fistulous
sinus pilonidalis, 3 as pyodermia, and 1 as perianal arborized
fistula. They all had a chronic inflammation of the affected region
with a continuous secernment to a larger or smaller extent. Thera
are is not Seven patients have been operated under the general
anaesthesia by the same team, and one under the peridural
anaesthesia. A wide surgical excision was applied to all of the
patients (Figure 3 and 4). The excision to the fascia was performed
in 5 cases, the excision with leave adipose tissue in 3. The
injection of methylene-blue into the sinuses was not done. None of
the cases included the covering of the tissue defect by a skin
graft. The skin defect was narrowed by rotating portions and Z
plastic on 3 patients (Figure 5 and 6). A larger part of the
postoperative wound healed per secundam. (Figure 7 and 8) Through
interviews, we determined the length of the preoperative treatment
and the level of the preoperative dissatisfaction related to the
disease. All the patients had been irritated by the disease
manifestation, and in 2 patients it reflected as a general state of
dissatisfaction. One had even been treated for depression.None of
them suffered the HS relapse, except the patient with the perianal
fistula (outer opening 10 cm from the anus). The fistula was
diagnosed during the operation. All but one patient were operated
on lying on their stomachs, slightly bent on the operating table.
The length of the hospital treatment was between 7 and 14 days or
until granulation started to develop, and the total treatment with
ambulance bandaging lasted over 2 months, all the way to the
complete forming of a stable scar and to a partial
epithelizing.During the postoperative interviews, all operated
patients showed functional satisfaction, even the one with the
fistula recidive. But the youngest and unmarried patient expressed
an aesthetic dissatisfaction. It points to the psycho-social
importance of the disease [5]. DiscussionNo increase of the HS
patients has been noticed in the last decades, but it is sure that
many essays on the disease have been published in the past 10 years
[6]. Although HS is not that rare, both the oversights in its
diagnostication and the under-estimation in its treatment are quite
frequent. The duration of the disease until the surgery is between
7 and 19 years [3]. As for our patients, the average time elapsed
up to the operation was 15 years. All our patients (except one who
was 73) ranged from 15 to 40 years of age, the same as in most of
the published works. All our patients was male contrary to the
statistics found in the literatureIs it a rare disease or not? By
the European criteria, a rare disease is the one with the frequency
smaller than 5 in 1000 cases or 0.05 %, and the American criteria
recognize the frequency bellow 0.08 % i.e. less frequently than 1
in 1250 people [7]. The European literature quotes the disease
frequency of 1 4 % [8, 9]. Some American sources mention the
frequency of only 0.053 %, which is a greatly underestimated
prevalence [10]. The most abundant data are given by Naldi L. in
his analysis of 9 studies which mention the frequency ranging from
4 in 100 to 1 in 3000. He explains such a discrepancy by
methodological differences. Nevertheless, he comes to a conclusion
that the value of 1 % is the most precise for many European
countries [11]. Most authors quote 2 to 5 times greater frequency
in women and the ages affected by the disease ranging from puberty
to 40 years of age [1, 12]. The cause of its pathogenesis is
unknown. It is common knowledge that hyperkeratotic production
occurs in the hair follicle and leads to the occlusion of the
output channel. Thus created cystoid formation grows into a small
abscess by the intrafollicular bacteria multiplication. The inner
follicular pressure increases and causes the rupture of the cystoid
formation and the creation of a tract in the surrounding
subcutaneous tissues fistulation (Figure 8). The healing and
recurrence of the inflammation lead to the hardening and thickening
of the tissue, as well as to the development of the chronic
infection with the skin maceration [13]. But the right question is
what initiates these processes? Etiological causes are: genetic
factors (family predisposition with the frequency of 30-40 % [14]),
overweight, smoking, changed cutaneo-immunological response and
hormone stimulation. The presence and multiplying of bacteria
together with a frequent mechanical skin irritation (friction)
bring about the development and aggravation of the disease [15]. We
think that is cause of dessease of our patients. Thorough anamnesis
and close inspection are all we need to diagnose the disease. The
localization and characteristic changes clearly point to HS, like
earla pictures seys. A biopsy may be performed only if a combined
disease is suspected [3]. The differential diagnosis takes into
consideration infected acne, furunculosis, cat scratch disease,
cellulitis, cutaneous blastomycosis, epidermoid cyst, erysipelas,
granuloma inguinale and lymphogranuloma venereum [16]. It may
co-exist with the following diseases: perianal fistula, sinus
pilonidalis, Crohns disease, irritable colon syndrome, Downs
syndrome, some forms of arthritis, Graves disease, Hashimotos
thyroiditis and Sjgrens syndrome [13]. HS shares the same
immunological etiology with some of these diseases. Certain
syndromes, in which HS is a part of the clinical picture, are
precisely defined, for example, PAPASH pyogenic arthritis,
pyodermia gangrenosum, acne and hidradenitis suppurativa. PASH,
PAPA and others have been noted earlier, too. They are believed to
be the consequences of gene mutation [17]. One our patient was
recidiv of perianal fistula. Preoperative fisical examination may
find internal opening in about 75% and TUS with 95% [30].HS can
also be the cause of the squamous-cellular carcinoma, especially in
the perianal region [18]. According to the morphological criterion
set by Hurley in 1989, the HS classification has 3 stadiums:1.
Isolated knots (a blind boil)2. Forming of fibroses and fistulous
(sinus) channels not connected into a unique area3. Confluent
fistulae, knots and hypertrophic scars. [19]There is also
Sartoriuss classification of the HS stadiums [20]. The treatment
mostly depends on the disease stadium: mild, medium and heavy forms
which correlate with Hurleys morphological picture. Even a few
death cases have been recorded due to HS.Our patient was classifaid
like Hurleys in stage 3. The HS patients quality of life is always
seriously decreased, especially in the stages of the disease which
are graver and more spread on the skin. Regarding the most
frequently affected age group, the disease can cause both
psychological and physical disorder of the patients sex life. In
any case, the social life of the sick is disrupted, as well as
their professional ability. That makes the social support and
psychological treatment necessary.The basic principle in the
management of HS is that an early and thorough surgical excision
gives the best results. The treatment includes: a local treatment:
disinfectants, light (photodynamic), laser treatment, local
antibiotics and other solutions; we dont uses too much; a
pharmacological and medicamentous treatment: immunosupressives and
immunomodulators, TNF alpha inhibitors, antibiotics, oral retinoids
and anti-androgens; we dont have thet medication; a surgical
treatment: deroofing, wide excision; - operations at 2 times, skin
grafts and other aesthetic operations like temporery solution; a
radiological treatment an external radiation, we dont usis; and a
psychological treatment.A radical surgery can be delayed in the
first stadium. As for the later stadiums, it is best to have a
surgical intervention as soon as possible, as our experience shows.
Generally, the operation can be delayed during the first stadium.
The shaving of the region and administering of antibiotics
according to the antibiogram are recommended instead, as well as
the local treatment of rinsing with antibiotic and disinfecting
solutions. The most common isolated causes of an infection are:
Staphilococcus aureus (51 %), then, Escherischia colli,
Streptococcus, anaerobes [17]. Various antibiotics are given like
our expirience : clindamycin, cephalosporin, tetracycline,
rifampicin and others. At recent time, the photodynamic therapy has
been used, as well as the laser therapy for the 1st and 2nd
stadiums [17]. We dont have, laike surgery, thet expirience. The
change of lifestyle in terms of a weight loss and giving up smoking
affects the treatment results in some patients. Because of the high
percentage of the relapsing, it is necessary to psychologically
prepare a patient to a long-lasting and, finally, surgical
treatment [19].According to Hurley, the surgical treatment is
applied in the 2nd and 3rd stadiums. It can be performed alone or
in the combination with a medication treatment. From literature we
can said: the medications used in the treatment are:
immunomodulatory medications (anakinra, cinakinumab, ustekunimab
improves condition in 2/3 of the HS patients and is also used in
psoriasis, azathioprine, tacrolimus, thalidomide) [7],
anti-inflammatory TNF-inhibitors (infliximab, etanercept,
adalimumab), immunosupressors (prednisone), dapson, antiandrogens
and acitretin. They have good effects when the disease is of the
autoimmune genesis. We did not use such treatment because all our
patients were in the 3rd stadium of the disease.Our patients
surgical therapy was always a wide excision of the change in the
gluteal region: to the fascia in 5 cases (one of them with several
different excisions of the affected cutaneous and subcutaneous
areas) and with the removal of the most part f the subcutaneous,
fat tissue except a thin layer above the fascia i.e. almost to the
fascia in the other 3 cases. Most authors agree that the surgical
treatment has no alternative in other types of treatments if we
want to come to a definite solution of the problem [21, 22, 23,
24]. A dilemma is whether to perform the excision to the fascia or
almost to the fascia until the granulation begins [25].After the
excision of the affected region, the following is possible: 1.
Leaving the wound to heal per secundam, 2. Healing per secundam
with a partial closing of some of the portions, 3. Delayed grafting
with an autologous skin portion in its full thickness [25], and 4.
Delayed grafting with an artificial graft [26]. The choice depends
on the size of a defect, risk of a recidive, risk of an infection
and expected aesthetic result. The healing per secundam and partial
narrowing of the excised area by skin portions, Z plastic, etc have
the smallest percentage of recidive and infection but the longest
treatment and poorest aesthetic result [26]. The grafting with skin
in its full thickness gives good results, but has a higher
percentage of infection [27]. More and more authors advocate the
grafting with an artificial skin graft. However, considering the
graft thickness and aesthetic aspect, it is not recommended to do
the excision to the fascia, but more moderately [28].We did not
perform the surgical procedure of cutting and opening the sinus
tracts with the removal of their surface parts (deroofing) and we
think it is a palliative measure with a high percentage of
relapsing [28]. It is good for the ambulance dealing with multiple
suppurations. We used simple and multiple incisions as a temporary
procedure. Some time ago, many advised the use of X-rays and laser
before the final operation (neodymium: yttrium-aluminium-garnet
laser with a 3 month application, or carbon dioxide laser). The
logical goal was to dry the affected area by the application of the
outer radiation in the amount of 3-8Gy in several fractions. A
study dating from the year 2000 cites radical withdrawal of the
changes in 1/3 of 231 cases [24].ConclusionHidradenitis suppurativa
is not a rare disease. The choice of the treatment methods is wide.
It is sure that keeping records of the patients improves the
treatment as they do in the Scandinavian countries with the
so-called HISREG [29] method of case registration. Our expirences
is thet a surgical treatment is not indicated in the early stages
of HS. When we speak of the advanced disease, only a surgery can
lead to healing. The affected regions are characteristic. All our
patiens was with gluteal region. When scars and sinus fistulae
begin to form, an early operation prevents the creation of more
serious aesthetic consequences. The operative management is a wide
excision without compromise and with one of the described ways of
the operative wound closing. Recidives on some parts of the
operated area are possible even after the surgery. In that case, a
re-excision is performed. Our patients did not suffer recidives of
the primary disease. The disease may be combined with other
diseases such as: fistulae, pilonidal sinus, immunosuppressive
states, or within the mentioned syndromes.
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Figure 1-2.: Hidradenitis suppurativa gr. III
Figure 3-4: Wide excision affected tissues
Figure 5-6: Primari reconstruction
Figure 7 8: Secondary stitch of the postoperative wound
Kratak sadrajUvod Hidroadenitis suppurativa je uporno,
zapaljenjsko, rekurento, oboljenje folikula korena dlake koje se
lako prenosi na znojne lezde to zajednino zapaljenje vremenom
dovodi do runih oiljaka. Kroz rad prikazujemo 8 operisanih
bolesnika u zadnje 3 godine. Mogunost previda u postavljanju
dijagnoze kao i potcenjivanje u tretmanu je prisutno. Uz operativne
metode prikazujemo i pregled drugih terapijskih mogunosti iz
literature kroz metod retrospektivne analize operativnih podataka i
intervjua sa bolesnicima. Zadnjih godina je otkriveno mnogo
podataka o etiologiji bolesti. Leenje je multidisciplinarno, ali
hirurka ekscizija je, kao to prikazuju nai rezuiltatu, jedina
opcija koja obezbeuje izleenje bez recidiva. Ekscizija se moe
izvesti do fascije ili uz ostavljanje tankog sloja masnog tkiva
(bilje prihvatanje transplantanta ili renja), a rekonstrukcija moe
biti zaceljenjem per secundam, autolognim konim ili arteficijalnim
graftom, ili suenjem rane konim renjem. Nai rezultati etapnim,
sekundarnim avovoma i rotacionim renjevima su
zadovoljavajui.Zakljuak Kad govorimo o uznapredovalom stadijumu
bolesti samo hirurgija obezbeuje izleenje. Operativni tretman je
iroka ekscizija to smo primenjivali sa nekim od prikazanih metoda
zatvaranja rane. Mogui su recidivi, a tada se praktikuje
re-ekscizija. Nai bolesnici nisu imali recidive primarne bolesti.
HS moe biti udruena sa perianalnim fistulama, pilonidalnim sinusom,
imunosupresivnim stanjima i drugim sindromima. Mi smo imali 1 sluaj
udruen sa fistulom. Kljune rei: hidradenitis suppurativa, znojna
lezda, hirurka ekscizija
asopis primam preko ustanove. Ukoliko je potrebno, posle
recenzije u uplatiti pretplatu ili kako je ve propisano.Prvi
autor
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