Hidradenitis suppurativa

Comorbidities, Clinical Presentation, Subtypes, and Treatment of HS Patients in Lithuania

Background: Hidradenitis suppurativa (HS) is a persistent, recurring skin inflammatory condition linked to various comorbidities. Management involves antibiotics, hormone therapy, immune-modulating drugs, surgery, and treatment of comorbidities. The objectives of the study were to assess the comorbidities, clinical presentation subtypes, and applied treatment of patients with HS. Methods: Patients with HS who visited the Centre of Dermatovenereology at Vilnius University Hospital Santaros Klinikos in Lithuania underwent evaluation based on the guidelines of the European Hidradenitis Suppurativa Foundation Registry questionnaire. Results: The study included 49 patients, and 61.22% (n = 30) had comorbidities. A strong positive correlation was found between a family history of inflammatory diseases (69.38% (n = 34)) and the severity of HS according to Hurley stage (r = 0.71 p < 0.05). A statistically significant correlation (r = 0.944, p = 0.02) was found between metabolic comorbidities and Hurley stage. Patients on biologic treatment had a mean IHS4 of 7.38 at the beginning of treatment and 3.22 at follow-up (p < 0.05). For patients not on biologics, the initial IHS4 score was 6.21 and 5.42 at follow-up (p > 0.05). Conclusions: A family history of inflammatory diseases and metabolic comorbidities showed a strong correlation with HS severity. Treatment with biologics showed significant improvement in HS scores compared to systemic antibiotics.

Fluorine-18 Fluorodeoxyglucose PET/CT Images of Hidradenitis Suppurativa Mimicking Metastasis in a Patient With Small Cell Lung Carcinoma

A 54-year-old male patient with metastatic small cell lung carcinoma received chemotherapy and in follow-up he was referred to positron emission tomography (PET)/CT scan for re-staging. In addition to the primary disease, increased Fluorine-18 fluorodeoxyglucose (F-18 FDG) uptake was detected in skin and subcutaneous fat tissue in the axillary, periscrotal, and perianal regions, which was later proven as hidradenitis suppurativa in PET/CT images.

Hidradenitis Suppurativa: Current Understanding of Pathogenic Mechanisms and Suggestion for Treatment Algorithm

Hidradenitis suppurativa is one of the most distressing dermatological conditions and has a significant negative impact on patients' quality of life. However, the exact pathogenic mechanisms remain incompletely understood and-therefore-efficient therapies are still lacking. The current manuscript focuses on new findings on its pathogenic mechanisms and aims to provide practical therapy recommendations.

The surgeon’s perspective: a retrospective study of wide local excisions taken to healthy subcutaneous fat in the management of advanced hidradenitis suppurativa

Background

Hidradenitis suppurativa (HS) is a chronic debilitating folliculopilosebaceous disease that affects the skin most commonly in the axilla, groin, inframammary, genital and buttock areas. Surgical intervention may be an appropriate option in selected cases, but there is a risk of recurrence. The purpose of this study was to assess the results of wide local excision (WLE) to healthy subcutaneous fat with secondary intention healing in patients with HS who were under concurrent surgical and dermatologic care.

Methods

We conducted a retrospective review of 192 consecutive HS consultations to a general surgical service, identifying patients treated with WLE. Cases involving minor procedures (deroofing, incision and drainage) were excluded. Data on patient demographics, surgical site, method of closure, complications and recurrence were extracted from patient charts. We also conducted a literature review of surgical procedures in the management of HS.

Results

A total of 66 patients underwent 133 WLE to healthy subcutaneous fat. All patients were under concurrent medical care directed by a dermatologist. No medical therapies, including biological treatments, were interrupted or withheld for surgery. One hundred procedures were closed primarily with rotation or advancement flaps and 33 by secondary intention healing. Local recurrence occurred in 18% of primary closures and 18% of secondary intention closures (p = 0.98, χ2 test, no difference between groups). One patient with secondary intention healing returned to the emergency department for bleeding; 34% of patients with primary closure experienced some dehiscence (23% major, 11% minor separation). Two patients with axillary disease had restrictions in their ability to raise their arm that required physiotherapy. Median follow-up was 14.5 (range 1–55) months.

Conclusion

Resection to healthy subcutaneous fat during WLE provides disease control comparable to that with deeper resections, simplifying care.

Hidradenitis suppurativa/acne inversa: a practical framework for treatment optimization - systematic review and recommendations from the HS ALLIANCE working group

Hidradenitis suppurativa (HS)/acne inversa is a debilitating chronic disease that remains poorly understood and difficult to manage. Clinical practice is variable, and there is a need for international, evidence‐based and easily applicable consensus on HS management. We report here the findings of a systematic literature review, which were subsequently used as a basis for the development of international consensus recommendations for the management of patients with HS. A systematic literature review was performed for each of nine clinical questions in HS (defined by an expert steering committee), covering comorbidity assessment, therapy (medical, surgical and combinations) and response to treatment. Included articles underwent data extraction and were graded according to the Oxford Centre for Evidence‐based Medicine criteria. Evidence‐based recommendations were then drafted, refined and voted upon, using a modified Delphi process. Overall, 5310 articles were screened, 171 articles were analysed, and 65 were used to derive recommendations. These articles included six randomized controlled trials plus cohort studies and case series. The highest level of evidence concerned dosing recommendations for topical clindamycin in mild disease (with systemic tetracyclines for more frequent/widespread lesions) and biologic therapy (especially adalimumab) as second‐line agents (following conventional therapy failure). Good‐quality evidence was available for the hidradenitis suppurativa clinical response (HiSCR) as a dichotomous outcome measure in inflammatory areas under treatment. Lower‐level evidence supported recommendations for topical triclosan and oral zinc in mild‐to‐moderate HS, systemic clindamycin and rifampicin in moderate HS and intravenous ertapenem in selected patients with more severe disease. Intralesional or systemic steroids may also be considered. Local surgical excision is suggested for mild‐to‐moderate HS, with wide excision for more extensive disease. Despite a paucity of good‐quality data on management decisions in HS, this systematic review has enabled the development of robust and easily applicable clinical recommendations for international physicians based on graded evidence.

Outcomes After Combined Radical Resection and Targeted Biologic Therapy for the Management of Recalcitrant Hidradenitis Suppurativa

BACKGROUND

Trials demonstrating the efficacy of biologic therapy for moderate to severe hidradenitis suppurativa (HS) have inspired new multidisciplinary treatment strategies. We present our experience with combined biologic and surgical therapy for recalcitrant HS.

METHODS

Between 2011 and 2014, 21 patients (57 cases) with Hurley Stage III HS underwent radical resection with delayed primary closure alone, or in combination with adjuvant biologic therapy. Demographic data, treatment regimen, outcomes, and complications were retrospectively reviewed for all cases.

RESULTS

Eleven patients underwent combined surgical and biologic therapy, whereas radical resection alone was performed in 10 patients. The average soft tissue deficit, before closure, for the combined and surgery-only patients was 56 cm and 48.5 cm, respectively (P = 0.66). Biologic agents including infliximab (n = 8) and ustekinumab (n = 3) were initiated 2 to 3 weeks after closure and were continued for an average of 10.5 months. Recurrence was noted in 19% (4/29) and 38.5% (10/26) of previously treated sites for combined and surgery-only patients (P < 0.01). For the combined cohort, the disease-free interval was approximately 1 year longer on average (P < 0.001); however, this difference was reduced to 4.5 months when considering time to recurrence after cessation of biologic therapy (P = 0.09). New disease developed in 18% (2/11) and 50% (5/10) of combined and surgery-only patients, respectively (P < 001). No adverse events were noted among patients who received biologic therapy.

CONCLUSIONS

Lower rates of recurrence and disease progression, as well as a longer disease-free interval may be achieved with the use of adjuvant biologic therapy after radical resection for recalcitrant HS.

Clinical Role of Modified Seton Procedure and Coring Out for Treatment of Complex Anal Fistulas Associated With Hidradenitis Suppurativa

A variety of techniques have been described to treat complex anal fistulas. When complex anal fistulas are associated with hidradenitis suppurativa, the treatment has to be appropriately tailored for the severity and distribution of the disease so as to remove the external fistula tract to prevent recurrence while ensuring fecal continence. Between 2007 and 2011, a total of 10 males (ranging in age from 32 to 54 years) complained of recurrent purulent discharge in the buttocks and thigh regions. The discharge had started about 12 to 18 months prior, and had increased progressively resulting in complex anal fistulas and hidradenitis suppurativa in the buttocks. They underwent surgical operation according to a modified seton procedure for complex anal fistulas and coring out for hidradenitis suppurativa. They were discharged from the hospital in 4 to 5 days, while the seton dropped spontaneously about 6 to 8 months after surgery. They have been well without any morbidities or recurrence. The present paper demonstrates that cases of complex anal fistulas associated with hidradenitis suppurativa can be successfully treated with a modified seton procedure and coring out of hidradenitis suppurativa.

Unconventional use of intense pulsed light

According to the literature, intense pulsed light (IPL) represents a versatile tool in the treatment of some dermatological conditions (i.e., pigmentation disorders, hair removal, and acne), due to its wide range of wavelengths. The authors herein report on 58 unconventional but effective uses of IPL in several cutaneous diseases, such as rosacea (10 cases), port-wine stain (PWS) (10 cases), disseminated porokeratosis (10 cases), pilonidal cyst (3 cases), seborrheic keratosis (10 cases), hypertrophic scar (5 cases) and keloid scar (5 cases), Becker's nevus (2 cases), hidradenitis suppurativa (2 cases), and sarcoidosis (1 case). Our results should suggest that IPL could represent a valid therapeutic support and option by providing excellent outcomes and low side effects, even though it should be underlined that the use and the effectiveness of IPL are strongly related to the operator's experience (acquired by attempting at least one specific course on the use of IPL and one-year experience in a specialized centre). Moreover, the daily use of these devices will surely increase clinical experience and provide new information, thus enhancing long-term results and improving IPL effectiveness.

A review of wide surgical excision of hidradenitis suppurativa

Background

Hidradenitis suppurativa (HS) is a chronic inflammatory cutaneous disorder that involves the infundibular terminal follicles in areas rich of apocrine glands. It can be associated with fistulating sinus, scarring and abscesses formation. Hidradenitis suppurativa is a challenging aspect and requires a proper treatment plan which may involve different specialties. We present herein the option of surgical treatment involving wide surgical excision and methods of reconstruction as well as the rate of recurrence. Furthermore, review of the literature regarding surgical treatment of hidradenitis suppurativa is provided.

Methods

A retrospective analysis reviewed 50 operative procedures for 32 patients in 5 anatomical sites. These anatomical sites have been divided to 23 sites involving the axilla, 17 sites involving the inguinal region and 8 sites involving the perianal/perineal area, 1 site involving the gluteal region and 1 site involving the trunk region.

Results

Twenty six patients (81, 25 %) showed no recurrence after surgery and the average time of hospital stay period was 5 days. Recurrence was observed only in 6 patients (18, 75 %).

Conclusion

Elimination of the acute inflammatory process should occur in advance, including the use of antibiotics and minor surgeries such as abscess drainage with proper irrigations. After stabilizing the acute phase, wide surgical excision is recommended. Herein, planning of surgical reconstruction should be initiated to achieve the best outcome and consequently decreasing the risk of recurrence and complications after surgery.

Management of regional hidradenitis suppurativa with vacuum-assisted closure and split thickness skin grafts

BACKGROUND

Hidradenitis suppurativa can be a debilitating chronic illness. The underlying cause of the disease is still not clear, but effective treatment of widespread regional disease relies on resection of all the involved skin and subcutaneous tissue. Closure of the resulting large wound is dependent on either flap or skin graft coverage. Many of the resulting wounds are too large for flap closure or result in unacceptable flap donor site deficits.

METHODS

We present a series of 11 patients with 24 regional disease sites treated with a protocol of excision, followed by wound vacuum-assisted closure (VAC; KCI, San Antonio, TX) therapy to stimulate angiogenesis of exposed fat, and then skin grafting with the use of VAC to support the grafts on the recipient sites.

RESULTS

Only 3 of the patients required regrafting. One patient had a VAC failure because of poor patient compliance, and 1 patient had 4 sites that each required regrafting as the epithelium would not fill in the residual open areas as it usually did in other patients. All patients were cured of their local disease.

CONCLUSIONS

Massive regional hidradenitis suppurativa can be successfully managed with wide excision, VAC therapy, and skin grafting to allow these patients to live normal and productive lives.

Gluteal and perianal hidradenitis suppurativa associated with tuberulosis

Perineal and gluteal hidradenitis suppurativa is a rare, chronic inflammatory disease of the skin caused by concomitant occlusion of the apocrine glands. We present a case report of a young male with no co-morbid conditions in which histopathology and DNA PCR showed association of chronic hyderadenitis suppurativa with tuberculosis. There was relapse after three months of completion of anti tubercular therapy. He was subsequently treated successfully with wide excision, split thickness skin grafting and a defunctioning stoma.

Perianal infections: a primer for nonsurgeons

The topic of perianal infections covers a broad range of illnesses that can be difficult to differentiate from each other. As a result, patients may suffer from unnecessary examinations and ineffective or delayed therapeutic interventions. This article reviews common and unusual infectious pathology and inflammatory or malignant conditions that should be considered in the differential diagnosis. Presentations of infectious pathology specific to HIV are discussed. New treatment strategies, where available, are noted.

Idiopathic pustular vulvitis

A 31-year-old woman presented in the 23rd week of her third pregnancy with extremely painful pustular vulvitis, unresponsive to antibiotics. Although the histological findings were was consistent with a diagnosis of hidradenitis suppurativa (HS), bridged comedones, the hallmark of this disease, were absent and there were no dermal sinuses. Incision and drainage of the pustules provided only temporary improvement, which was briefly maintained with oral clindamycin and topical steroids. After the birth, a course of isotretinoin produced almost total clearance, a response not typically found in HS. This patient's condition may represent a variant of HS, and if so, it would be the first case report of de novo HS in pregnancy, but its clinical features and evolution differed so much from those in HS that the possibility of a previously unrecognised condition cannot be excluded.

Outcomes of treatment of nine cases of recalcitrant severe hidradenitis suppurativa with carbon dioxide laser

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic and often a recalcitrant inflammatory skin condition.

OBJECTIVES

To present the results of carbon dioxide (CO2) laser treatment of recalcitrant HS in nine patients who had failed to improve on medical and other surgical treatments.

METHODS

HS lesions consisting of abscesses, sinuses and granulation tissue were completely excised using the cutting mode of a CO2 laser, leaving only healthy residual subcutaneous fat. The wounds were closed by primary intention where possible and left to granulate otherwise. Outcomes were determined by clinical review and questionnaire.

RESULTS

Twenty-seven sites were treated in 19 sessions on nine patients. Seven procedures were performed under general anaesthesia and 12 under local. All patients rated their postoperative discomfort as less or equal to their preoperative state. Seven of the nine patients had complete remission for 12 months or longer after their last laser treatment and ceased all medications. High levels of patient satisfaction were reported with CO2 laser treatment. The main complication was axillary scar contracture in two patients but this was insufficient to limit limb movement.

CONCLUSIONS

CO2 laser treatment should be considered as a treatment option in recalcitrant HS, where multiple medical treatments have been ineffective.

Granulocyte-macrophage colony-stimulating factor for perianal hidradenitis suppurativa: report of a case

Perianal hidradenitis suppurativa is a chronic inflammatory disease associated with significantly high morbidity, which severely affects the quality of life of those patients suffering from it. We describe a 46-year-old patient with extensive, severe gluteal and perianal PHS of 28 years duration. Repeated wide excisions, fistulotomies, treatments with hyperbaric oxygen, and finally a diverting colostomy were unsuccessful. A new form of treatment with repeated perilesional injections of granulocyte-macrophage colony-stimulating factor, in conjunction with surgical procedures, was performed with excellent results.

Un lambeau sur mesure dans un cas évolué de maladie de Verneuil s'étendant à la région génitale

Hidradenitis suppurativa is a chronic, suppurative and scarring disease characterized by painful, inflamed lesions in the axillae, perineum, groin, scrotum and other parts of the body with apocrine-bearing skin including genital skin. Appropriate medical treatment alone appears to be insufficient for managing most patients with severe lesions. In the vast majority of cases, surgery consists in complete excision of the lesions with primary closure or healing by secondary intention. In severe cases, radical excision of all diseased apocrine-bearing skin is mandatory and the resulting defects are generally repaired by mesh skin grafts. In the most severe cases it may be necessary to realize loco-regional flaps. Generally we reconstruct the perineal region with bilateral fasciocutaneous thigh flaps. We report a case of hidradenitis suppurativa where the lesions were so extensive from penis to anus we had to imagine a tailor-made flap based on the abdominoplasty techniques.