Patient Impressions and Outcomes After Clinic-Based Hidradenitis Suppurativa Surgery

Hidradenitis Suppurativa Tunnels: Unveiling a Unique Disease Entity

Hidradenitis suppurativa tunnel structures lined with epithelium within the dermis are unique features of advanced disease stages that significantly impair patients' QOL. The presence of hidradenitis suppurativa tunnels is associated with a decreased likelihood of achieving a clinical response, even when receiving biological therapy. The cellular and molecular mechanisms underlying tunnel formation and pathology are only partially understood, which hampers the development of more effective targeted therapies. Tunnels create a unique microenvironment that drives a vicious cycle of hidradenitis suppurativa inflammation, with tunnel keratinocytes exhibiting an activated phenotype characterized by distinct gene expression signatures. In this review, we summarize the current literature and discuss aspects of the pathophysiology of tunnels, including the role of hair follicle epidermal stem cells in tunnel formation, potential role of fibroblast-mediated epithelial-mesenchymal transition, role of dermal papilla fibroblasts, and aberrant proinflammatory repair response contributing to the observed fibrosis and scarring. Finally, tunnel structures are characterized by unique microbial dysbiosis and an overabundance of Gram-negative anaerobes that are not targeted by current therapeutics. In addition to outlining the possible mechanisms of tunnel formation, we provide perspectives on the translation of current knowledge into more effective treatment approaches for patients with hidradenitis suppurativa tunnels.

Cost-utility analysis of clinic-based deroofing versus local excision for hidradenitis suppurativa

BACKGROUND

Deroofing and local excision are common clinic-based surgical options for hidradenitis suppurativa. Evidence suggests deroofing may have lower rates of adverse events (AEs), defined as disease recurrence or postsurgical complications.

OBJECTIVE

This cost-utility analysis evaluates the economic and health-related impacts of clinic-based deroofing vs excision for hidradenitis suppurativa, comparing direct medical costs and quality-adjusted life-years (QALYs).

METHODS

A Markov model was developed based on a literature review of clinical outcomes, EQ-5D utilities, and resource utilization. Patients began in a preprocedural state and transitioned monthly among 3 health states: responders (no AEs), nonresponders (≥1 AE), and death. The model assessed cost-effectiveness over a 2-year horizon from the U.S. healthcare system perspective.

RESULTS

Deroofing provided an additional 0.19 QALYs at a cost of USD$311.39 per patient relative to excision, yielding a favorable incremental cost-effectiveness ratio of USD$1677.10/QALY, below the USD$50,000/QALY threshold.

LIMITATIONS

Methodological constraints from limited published data were addressed through multiple sensitivity analyses. Cost-effectiveness was sensitive to AE rates, secondary costs, and utility values.

CONCLUSION

When clinically appropriate, deroofing is more cost-effective than excision for clinic-based procedural management of HS, offering improved quality of life at a modest incremental cost.

Hidradenitis Suppurativa in Children

Hidradenitis suppurativa (HS) in children can be especially challenging to treat due to a lack of pediatric-specific data and guidelines. Management strategies for this special population are often extrapolated from the adult HS literature. Many treatments, including topical agents, oral antibiotics, hormonal agents, biologics, and procedures, often utilized for adults, may also be implemented in children; however, certain age-specific considerations should be noted. Early identification and treatment of HS may help reduce the development of irreversible tissue damage and mitigate potentially devastating impacts on mental health and physical functioning.

Procedural Interventions for Hidradenitis Suppurativa

A variety of procedures may be employed for hidradenitis suppurativa, a chronic cutaneous condition that causes abscesses, nodules, and tunnels in skinfold areas. Intralesional steroid or incision and drainage are preferred for acutely inflamed discrete lesions, while deroofing or excision may be pursued for persistent or recurrent areas. Excision and deroofing may target individual lesions or complete regions that are more widely affected. Reconstructions may be considered after excisions based on operator and patient preference. Other procedures such as botulinum toxin injection, cryoinsufflation, and electrosurgical and laser-based modifications to deroofing and excisions have also been used successfully.

A young woman's experience of surgery for severe hidradenitis suppurativa

A young woman with severe hidradenitis suppurativa describes her struggles with the disease and the impact surgery has had on her life.

Hidradenitis Suppurativa Surgery Complication Rates Among Patients With Obesity or Diabetes or Who Smoke: A Review

Importance

Surgery is frequently required for hidradenitis suppurativa (HS) treatment, but the impact of common comorbidities such as obesity, diabetes, and smoking on outcomes has been sparsely studied.

Observations

A total of 12 studies met final inclusion criteria for investigating complication rates associated with at least 1 comorbidity. Complication rates were associated with obesity in 3 of 10 studies. Obesity was modestly associated with dehiscence and readmission for flap reconstruction, debridement, and skin-grafting techniques in one study, dehiscence in a second, and delayed wound healing in another. One of 5 studies that reported complication rates in patients with diabetes found increased hospital readmissions for debridement (deroofing or excision without flap/graft) and flap reconstruction. No studies evaluating smoking found increased associated risks.

Conclusions and Relevance

This review highlights a greater need for consistent analysis and reporting of the surgical outcomes among patients with HS and certain comorbidities. Further rigorous clinical trials are needed to validate these findings and improve access to surgery in this patient population.

Innovations in Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition characterized by painful, recurrent abscesses, inflammatory nodules, and draining tunnels. Biologic and small molecule therapeutics are effective for treatment of moderate-to-severe HS. The field of HS is rapidly growing with numerous ongoing clinical trials exploring novel agents. This review highlights the latest discoveries in the field of HS, with a particular focus on novel therapeutic agents and procedural management.

Taiwanese Dermatological Association (TDA) consensus recommendations for the definition, classification, diagnosis, and management of hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory follicular disease characterized by painful, recurrent, inflamed lesions most commonly occurring in the axillary, inguinal, and anogenital regions. HS can inflict immense physical and psychological impact on patients who suffer from this distressing disease. Management of HS generally requires combining various medical and procedural treatment modalities; however, the disease is often recalcitrant to conventional treatments. In light of recent evidence supporting the effectiveness of biologic agents in the treatment of HS, the Taiwanese Dermatological Association established an expert panel of nine dermatologists to develop consensus statements aimed to provide up-to-date evidence-based guidance in optimizing HS patient management in Taiwan. The recommendations described in the statements were summarized in a management algorithm in terms of general care, topical treatment, systemic treatment, and procedural treatment.

Predictors of wound healing after surgical deroofing in Hidradenitis Suppurativa

BACKGROUND/OBJECTIVES

Surgical deroofing is an essential part of ongoing management of Hidradenitis Suppurativa, including persistent lesions non-responsive to medical therapy. The variables associated with delayed wound healing after surgical deroofing are contradictory within the literature due to the inclusion of heterogeneous surgical intervention methods. We aimed to assess the predictors of time to wound healing after surgical deroofing in HS.

METHODS

Patients who underwent in-office surgical deroofing between 2020 and 2024 at a single tertiary HS referral centre were included in analysis. Demographic, disease and blood variables were collected as per standard of care. Statistical analysis was performed using univariate correlation, with multiple regression performed to explore the interactions between variables and identify variables predictive of time to wound healing.

RESULTS

A total of 270 individuals were included in the analysis. The median time to wound healing was 9.6 weeks with a range from 4 to 22 weeks. Kaplan-Meier curves demonstrated significant differences with the log rank test when comparing biologic use versus no use, normal versus abnormal CRP and normal versus abnormal haemoglobin. Cox regression analysis identified biologic use with a significant hazard ratio compared to no biologic therapy (HR = 2.512, p < 0.0001) along with baseline CRP (HR = 0.968, p < 0.0001) and baseline haemoglobin (HR = 1.052, p < 0.001).

CONCLUSIONS

Time to wound healing after in-office deroofing can be decreased with prior biologic therapy and markers of systemic inflammation in blood are also significantly associated with delays in healing. This correlates well with the existing literature promoting concurrent medical and surgical therapy to improve patient outcomes in HS.

Procedural treatments for hidradenitis suppurativa

Procedural treatments for hidradenitis suppurativa play a pivotal role in management of patients with hidradenitis suppurativa when used in combination with medical therapy. Laser, light, and surgical procedures can be used to improve a patient's symptoms and quality of life. Understanding how and when to use these treatments effectively is important for long-term hidradenitis suppurativa management.

Surgical outcomes of hidradenitis suppurativa: evaluating factors influencing recurrence and complications after 284 complete excisions

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic inflammatory disorder associated with tunnel formation and scarring. Surgical excision is a potential curative therapy for HS.

OBJECTIVES

To characterize the surgical outcomes of patients with HS undergoing complete excision and to identify the risk factors associated with postoperative recurrence.

METHODS

This retrospective 16-year cohort study enrolled patients ≥ 20 years who underwent complete excision for HS lesions at the National Taiwan University Hospital. We assessed the rates of postsurgical recurrence and complications and estimated the odds ratio (ORs) with 95% confidence intervals (CIs) of their association with potential risk factors using generalized estimating equations.

RESULTS

In total, 136 patients with HS and the 284 corresponding complete excisions were identified. Recurrence developed in 88 of 284 (31.0%) operations and complications occurred in 102 (35.9%). Common types of complications included wound dehiscence, hypertrophic scars and surgical-site infection. Clinical factors associated with a lower risk of recurrence were male sex [adjusted OR (aOR) 0.48, 95% CI 0.23-0.98], surgery at atypical body sites (aOR 0.28, 95% CI 0.08-0.99) and wound repair by split-thickness skin graft (aOR 0.31, 95% CI 0.12-0.77). Wound dehiscence was associated with an increased risk of recurrence (aOR 2.55, 95% CI 1.21-5.42). No independent factors were identified as being associated with composite postoperative complications.

CONCLUSIONS

Complete excision alone can be effective in curing HS in Asian populations. Recurrence developed in about one-third of the complete excisions performed for HS. Sex, surgical body sites, methods of wound repair and wound dehiscence were major determinants for recurrence.

Management of Pilonidal Disease and Hidradenitis Suppurativa

Pilonidal disease and hidradenitis suppurativa affect healthy young adults, causing discomfort and pain that leads to loss of work productivity and should be approached in a personalized manner. Patients with pilonidal disease should engage in hair removal to the sacrococcygeal region and surgical options considered. Hidradenitis suppurativa can be a morbid and challenging disease process. Medical management with topical agents, antibiotics, and biologics should be used initially but wide local excision should be considered in severe or refractory cases of the disease.

Treatment of Hidradenitis Suppurativa Evaluation Study: the THESEUS prospective cohort study

Background

Hidradenitis suppurativa is a chronic inflammatory skin disease characterised by recurrent inflammatory lesions and skin tunnels in flexural sites such as the axilla. Deroofing of skin tunnels and laser treatment are standard hidradenitis suppurativa interventions in some countries but not yet introduced in the United Kingdom.

Objective

To understand current hidradenitis suppurativa management pathways and what influences treatment choices to inform the design of future randomised controlled trials.

Design

Prospective 12-month observational cohort study, including five treatment options, with nested qualitative interviews and an end-of-study consensus workshop.

Setting

Ten United Kingdom hospitals with recruitment led by dermatology and plastic surgery departments.

Participants

Adults with active hidradenitis suppurativa of any severity not adequately controlled by current treatment.

Interventions

Oral doxycycline 200 mg once daily; oral clindamycin and rifampicin, both 300 mg twice daily for 10 weeks initially; laser treatment targeting the hair follicle (neodymium-doped yttrium aluminium garnet or alexandrite); deroofing; and conventional surgery.

Main outcome measures

Primary outcome was the proportion of participants who are eligible, and hypothetically willing, to use the different treatment options. Secondary outcomes included proportion of participants choosing each of the study interventions, with reasons for their choices; proportion of participants who switched treatments; treatment fidelity; loss to follow-up rates over 12 months; and efficacy outcome estimates to inform outcome measure instrument responsiveness.

Results

Between February 2020 and July 2021, 151 participants were recruited, with two pauses due to the COVID-19 pandemic. Follow-up rates were 89% and 83% after 3 and 6 months, decreasing to 70% and 44% at 9 and 12 months, respectively, because pandemic recruitment delays prevented all participants reaching their final review. Baseline demographics included an average age of 36 years, 81% female, 20% black, Asian or Caribbean, 64% current or ex-smokers and 86% with a raised body mass index. Some 69% had moderate disease, 19% severe disease and 13% mild disease. Regarding the study's primary outcome, laser treatment was the intervention with the highest proportion (69%) of participants who were eligible and hypothetically willing to receive treatment, followed by deroofing (58%), conventional surgery (54%), the combination of oral clindamycin and rifampicin (44%) and doxycycline (37%). Considering participant willingness in isolation, laser was ranked first choice by the greatest proportion (41%) of participants. The cohort study and qualitative study demonstrated that participant willingness to receive treatment was strongly influenced by their clinician. Fidelity to oral doxycycline was only 52% after 3 months due to lack of effectiveness, participant preference and adverse effects. Delays receiving procedural interventions were common, with only 43% and 26% of participants commencing laser therapy and deroofing, respectively, after 3 months. Treatment switching was uncommon and there were no serious adverse events. Daily pain score text messages were initiated in 110 participants. Daily responses reduced over time with greatest concordance during the first 14 days.

Limitations

It was not possible to characterise conventional surgery due to a low number of participants.

Conclusion

The Treatment of Hidradenitis Suppurativa Evaluation Study established deroofing and laser treatment for hidradenitis suppurativa in the United Kingdom and developed a network of 10 sites for subsequent hidradenitis suppurativa randomised controlled trials.

Future work

The consensus workshop prioritised laser treatment and deroofing as interventions for future randomised controlled trials, in some cases combined with drug treatment.

Trial registration

This trial is registered as ISRCTN69985145.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 12/35/64) and is published in full in Health Technology Assessment; Vol. 27, No. 30. See the NIHR Funding and Awards website for further award information.

Hidradenitis suppurativa perspectives during the COVID-19 pandemic

The COVID-19 pandemic created a new set of challenges regarding the care of patients with hidradenitis suppurativa (HS). Access to safe, timely medical care and the use of immunosuppressive therapy were central topics of concern for patients and providers. In addition, the incidence and severity of SARS-CoV-2 infection in patients with HS were critical to examine during the evolving pandemic and to provide recommendations for patients for makinginformed decisions about their disease and its management. Another consideration of the COVID-19 pandemic was the role of the internet to connect individuals with HS with each other and experts in the field. This is a unique contribution that collectively examines the perspectives of HS medical care and support during the COVID-19 pandemic.

Treatment of severe Hidradenitis suppurativa with a combination of 5-aminolevulinic acid photodynamic therapy, surgery, and secukinumab

Hidradenitis suppurativa (HS) is a chronic inflammatory disease characterized by nodules, abscesses, fistulas, sinus tracts, and scars, typically in intertriginous areas [1]. Therapeutic options include medications, surgical interventions, and physiotherapy; however, clinical management is challenging. We report a case of HS that was refractory to multiple treatments and achieved complete remission with a combination therapy of surgery, 5-aminolevulinic acid photodynamic therapy (ALA-PDT), and secukinumab.

Innate immunity and microbial dysbiosis in hidradenitis suppurativa - vicious cycle of chronic inflammation

Hidradenitis Suppurativa (HS) is a chronic multifactorial inflammatory skin disease with incompletely understood mechanisms of disease pathology. HS is characterized by aberrant activation of the innate immune system, resulting in activation of pathways that aim to protect against pathogenic microorganisms, and also contribute to failure to resolve inflammation. Imbalance in innate immunity is evident in deregulation of host antimicrobial peptides (AMPs) and the complement system associated with the microbiome dysbiosis. The pathology is further complicated by ability of pathogens associated with HS to overcome host immune response. Potential roles of major AMPs, cathelicidin, defensins, dermcidin, S100 proteins, RNAse 7 and complement proteins are discussed. Dysregulated expression pattern of innate immunity components in conjunction with bacterial component of the disease warrants consideration of novel treatment approaches targeting both host immunity and pathogenic microbiome in HS.