Surgical Management of Hidradenitis Suppurativa

Abstract

Hidradenitis suppurativa (HS) is a chronic, relapsing inflammatory disease of the skin, characterized by recurrent draining sinuses and abscesses, predominantly in skin folds carrying terminal hairs and apocrine glands. Treatment for this debilitating disease has been medical management with antibiotics and immune modulators. With the advent of better reconstructive surgical techniques, the role of surgery in the treatment of HS has expanded, from being a last resort to a modality that is deployed earlier. Larger defects can be more easily reconstructed, allowing for a more radical excision of diseased areas. Locoregional flaps, perforator flaps, and propeller flaps that use the fasciocutaneous tissue allow reconstruction of defects with similar tissue, and provide better cosmetic and functional outcomes. They are easy to execute and can be performed even in resource-poor settings with concurrent use of immune modulators and postoperative antibiotics. Hidradenitis can be successfully treated with surgery in early stages as well as severe disease, due to the advances in understanding disease behavior, multidisciplinary care, and advanced reconstructive techniques. Coupled with a multidisciplinary care team, surgery offers a durable, lasting cure for HS, significantly reducing disease morbidity.

Fig. 1.

First-line nonsurgical management of HS. NSAIDs, non-steroidal anti-inflammatory drugs; TNF, tumor necrosis factor.

Fig. 2.

Stage-specific first-line therapy for HS. PO, per oral; BID, twice daily; QD, once daily.

Fig. 3.

Multidisciplinary care model for hidradenitis patients.

Fig. 4.

Reconstructive choices based on anatomic location of lesions. ICAP, intercoastal artery perforator; TRAM, transverse rectus abdominis myocutaneous; SIEA, superficial inferior epigastric artery.

Fig. 5.

Case 1. A 23-year-old man (body mass index = 40) with a 10-year history of bilateral axillary hidradenitis (Hurley stage III) unresponsive to topical and oral antibiotics and Humira. A–B, preoperative and after wide resection (20 × 15 cm) with immediate TDAP fasciocutaneous flap (22 × 10 cm) reconstruction [based on two perforators (shown in C)] was performed. Surrounding tissue was widely undermined and (D) flap inset was undertaken loosely (body mass index considerations). Patient was admitted postoperatively, taken back on POD 2 for final inset, and discharged on POD 4. The patient did well postoperatively, and will be undergoing right HS wide local excision and reconstruction. E, One month postoperative appearance.

Fig. 6.

Case 2. A 21-year-old woman with a 5-year history of perineal/gluteal hidradenitis (Hurley stage III). Topical treatments were ineffective, and she refused systemic medical therapies. After wide local excision (A), a superior gluteal artery perforator fasciocutaneous flap based on two parasacral artery perforators [with a 90-degree pivot; perforators marked with x (B)] was used for reconstruction (C). Postoperatively, the patient was kept on prone bed rest for 1 day and then out of bed as tolerated with sitting and supine laying restrictions for 6 weeks. On the inferior aspect of the flap, the patient developed a small dehiscence, primarily closed in the office.

Fig. 7.

What providers of care for HS patients need to know.

Fig. 8.

What HS patients need to know.