What's new in hidradenitis suppurativa?

Modified Posterior Arm Flap for Axillary Hidradenitis Suppurativa

INTRODUCTION

Hidradenitis suppurativa (HS) is a chronic, inflammatory condition of the apocrine sweat glands present in 1% to 4% of the adult population, with twice greater prevalence in females. Surgical excision is the criterion-standard treatment for advanced, grade III disease, characterized by extensive and recurrent abscesses and interconnected sinus tracts. Numerous reconstructive methods have been used to cover the resulting defects, including secondary intention healing, use of skin grafts, and a wide range of locoregional flaps.

METHODS

The modified posterior arm flap has been developed for reconstruction of axillary defects after radical excision of HS. Based on perforating vessels from the axillary artery first identified by Masquelet, a brachioplasty-like incision is used to keep the donor site closure relatively hidden on the posteromedial aspect of the inner arm.

RESULTS

Eight modified posterior arm flaps have been undertaken in 6 patients, all women (mean age, 35 years; range, 22-51 years) from 2014 to 2019. All patients had complete resolution of their HS symptoms with no incidences of recurrence at mean follow-up of 15 months. All reported satisfaction with the aesthetic and functional outcomes of the procedure.

DISCUSSION

We present a novel modification of the posterior arm flap for the treatment of advanced axillary HS with good functional and aesthetic outcomes and no incidences of recurrence.

Axillary Reconstruction for Hidradenitis Suppurativa with an Inner-Arm Transposition Flap Creating a Brachioplasty Effect

Background

Hidradenitis suppurativa (HS) is a chronic skin condition that can affect any area with apocrine sweat glands and has the potential to involve multiple sites concurrently. Commonly affected sites include the axilla, groin, perineum and perianal areas. In this study we performed a literature review on the surgical methods for HS and describe an innovative technique for reconstructing axilla HS using an inner-arm transposition flap.

Methods

We reviewed all cases (5 cases from 4 patients) of transposition flap reconstruction performed by the senior author at a single London tertiary hospital from 2008–2013. Patient related outcome measures were collected using the Derriford appearance scale (DAS 24) and a study specific questionnaire.

Results

All patients were satisfied with their final result. One out of five cases had a complication but did not result in flap failure. There is no disease recurrence to date. DAS 24 scores collected demonstrated acceptable postoperative distress that did not deviate far from the norm tables while study specific questionnaire reveal desirable outcomes.

Conclusions

We have managed to achieve our aim through the use of the innovative inner-arm transposition flap. Our study hopes to provide an additional technique for axillary reconstruction. This technique offers the effective concealment of scars with the benefit of tightening of the arm tissue producing ‘brachioplasty like’ effects. All things considered it would be reasonable to conclude the innovative flap technique is a reliable, effective, and simple method that results in multiple benefits.

Hidradenitis Suppurativa in 64 Female Patients: Retrospective Study Comparing Oral Antibiotics and Antiandrogen Therapy

Background:

Hidradenitis suppurativa (HS) is a recurrent disease confined to apocrine gland-bearing areas causing painful, deep-seated lesions and draining sinus tracts. Uniformly effective therapy is lacking. Improvements in current medical management strategies are needed.

Objective:

We sought to determine the success rate for a variety of treatments in our female HS patients and whether androgen-related tests can predict a response to antiandrogen therapy. As HS has been linked to a hyperandrogen state, we sought to determine if it is also associated with polycystic ovary syndrome (PCOS).

Methods:

A retrospective chart review was performed examining hormonal profiles and the response to a variety of treatments in female patients with HS.

Results:

Sixty-four female HS patients were identified (mean age 33 years). Antiandrogen therapy was superior to oral antibiotic therapy (55% vs 26%) based on a two-sample, two-sided, t-test statistic (p < .04). The prevalence of PCOS among our study patients in whom androgen markers were available was 8 of 21 (38.1%), and even if taken over all study patients, not necessarily investigated for PCOS, the prevalence was 8 of 64 (12.5%). This reflects a greater than expected prevalence among all women (10%).

Conclusion:

As a proof-of-concept study, despite limitations inherent in a retrospective chart review, there is sufficient signal to suggest that a hormonal manipulation approach to therapy should be considered in all women presenting with HS. Female patients presenting with HS should prompt investigations for underlying PCOS and insulin resistance.

Intramuscular immunoglobulin for recalcitrant suppurative diseases of the skin: a retrospective review of 63 cases

BACKGROUND

Intramuscular human immunoglobulin (HIG) may provide a therapeutic option as an independent or combined treatment for recalcitrant suppurative skin diseases such as hidradenitis suppurativa, folliculitis decalvans, or chronic recurrent furunculosis or folliculitis.

OBJECTIVES

To define the efficacy and safety of intramuscular HIG for chronic and recalcitrant suppurative skin diseases.

METHODS

Patients who had received HIG for hidradenitis suppurativa, folliculitis decalvans, furunculosis or folliculitis at Severance Hospital, Seoul, Korea, between January 2000 and May 2005 were identified from medical/pharmacy records. All records were analysed retrospectively.

RESULTS

Sixty-three patients were identified. After treatment, 37 patients (59%) showed overall improvement and were rated as having an 'excellent response' or 'good response' by the attending physician. No improvement or worsening was seen in only three patients (5%). A period without new lesions (PWNL) was achieved in 46 patients (73%). The number of times HIG was administered to achieve PWNL ranged from 1 to 12 (mean +/- SD 2.15 +/- 1.69). There was no significant difference in the rating score between the independent intramuscular HIG and the combined treatment groups. Pain at the injection site was the major side-effect, which led to the discontinuation of treatment in five patients. No other significant systemic side-effects were observed.

CONCLUSIONS

Our results demonstrate that intramuscular HIG may be used for the treatment of recalcitrant suppurative skin diseases as an independent or combined treatment.

Surgical treatment of hidradenitis suppurativa: case series and review of the literature

The chronic and relapsing nature of hidradenitis suppurativa leads to physical and psychological damage. The absence of a proven cure further worsens the scenario. Patient 1 was a 28-year-old woman with a 10-year history of abscesses and non healing sinuses with foul-smelling discharge from her axilla, submammary and groin areas. This led to an episode of self-harm due to severe depression. After failed medical therapy, she was referred for surgery with wide excision of the skin and healing by secondary intention. Her wounds were managed by our specialist wound clinic with the use of topical and systemic antibiotics and thus remained free from symptoms. Patient 2 was a 32-year-old woman with a similar history for 15 years. Patient 3 was a 41-year-old man with a 20-year history of discharging sinuses and abscesses. All the patients had endured a long period of medical treatment and subsequently required surgery for a long-term relief of symptoms. This has undoubtedly led to psychological symptoms and a decrease in quality of life.