Surgical treatment of chronic hidradenitis suppurativa: CO2 laser stripping-secondary intention technique

Laser and intense pulsed light in the treatment of hidradenitis suppurativa

Treatment of hidradenitis suppurativa (HS) requires a combination of medical, surgical, and lifestyle interventions. Intense pulsed light (IPL) and lasers have been reported to be useful. The aim of this review is to find the evidence supporting IPL and laser treatment of HS and to provide guidance for the management of specific HS lesions. We searched PubMed and Web of Science for "laser" and "hidradenitis suppurativa" on April 6, 2022. Inclusion criteria were >10 patients, reported follow-up, English language, and human subjects with a diagnosis of HS. A total of 724 articles were screened, but only 17 studies qualified for inclusion (IPL (n = 4), Nd:YAG (n = 6), CO2 laser (n = 6), and intralesional treatment (n = 2). The majority of the studies had a low (n = 10) or moderate (n = 7) evidence level. Treatment effect was noticed in studies using IPL and Nd:YAG (hair reduction). CO2 laser was used for surgery with a success rate ranging from 70.7% to 96.7%. CO2 laser is useful for surgery of stationary HS lesions, but it is difficult to draw a conclusion on the use of IPL and Nd:YAG (hair reduction) as the studies were too heterogeneous to perform a meta-analysis.

Evaluation of Outcomes Following Surgical Treatment of Hidradenitis Suppurativa

Hidradenitis suppurativa (HS), a chronic disease of the apocrine bearing skin causing induration, pain, draining sinuses, and subcutaneous abscesses, significantly impairs patients' quality of life (QOL). Full-thickness excision followed by skin grafting of the involved area can be curative. Herein, we evaluated the impact of this surgical treatment on QOL and depression symptomatology. Adult patients (≥18 years) who consented to participate filled out the dermatology quality of life (DLQI) and the Patient History Questionnaire (PHQ-9) at consent and at 1, 6, and 12 months post-initial evaluation and surgery. Demographics, HS, admission, and operative information were collected. Sixteen patients were included. Subjects were mainly white (81.3 %) and female (56.3%) with a median age of 38.2 (Interquartile range: 34.2-54.5); 62.5% were obese (BMI= 39.7 [28.4-50.6]). Half of the subjects presented with HS in 2 or more areas. Six patients were still undergoing surgeries at 6 months. One-, six-, and 12-month follow-up surveys were obtained from 14, 11, and 8 subjects for DQLI and from 14, 9, and 5 subjects for PHQ9. DLQI scores significantly decreased at 6 months compared to baseline, which indicates QOL improvement (10 [4-20] vs 15.5 [12-21.8], P = .036). Although not significant, PHQ9 scores tended to decrease. For those with the worst disease, DLQI significantly decreased at both 6 (P = .049) and 12 months (P = .047) compared to baseline. Despite a small sample size, our data suggest that aggressive surgical treatment improves the QOL of HS patients. Further studies are warranted to confirm our findings.

Emerging Treatments and the Clinical Trial Landscape for Hidradenitis Suppurativa-Part II: Procedural and Wound Care Therapies

Procedural treatments are a cornerstone of hidradenitis suppurativa (HS) management. New interventional therapies are being studied as part of the upsurge in HS research and clinical trials. Additionally, draining wounds can impart a significant negative impact on patients' quality of life, requiring daily dressing changes. However, standardized guidelines on how to best manage HS wounds both day-to-day and post-procedure are lacking. In part II of this emerging therapies review, procedural treatments and wound care dressings and devices that are being investigated for HS management are discussed.

Clinical-Epidemiological Characteristics of Hidradenitis Suppurativa: A Retrospective Cohort Study from a Tertiary Care Centre in Northern Israel

BACKGROUND

Hidradenitis suppurativa (HS) is characterised by inflamed lesions that typically appear in apocrine-rich flexural areas. Although studies have reported clinical and epidemiological data from western countries, data from the Middle East are scarce. The aim of this study is to characterise the differences in the clinical characteristics of patients with HS of Arab and Jewish ancestry and review the clinical characteristics, the course of the disease, the comorbidities, and the response to treatment.

METHODS

This is a retrospective study. We collected clinical and demographic data from patient files between 2015-2018 at the Rambam Healthcare Campus dermatology clinic-a tertiary hospital located in the north of Israel. Our results were compared to those of a previously published Israeli control group registered in Clalit Health Services.

RESULTS

Of the 164 patients with HS, 96 (58.5%) were men and 68 (41.5%) were women. The average age at diagnosis was 27.5 years and the average latency between the onset and diagnosis of the disease was 4 years. We found a higher adjusted prevalence of HS in Arab patients (56%) than in their Jewish counterparts (44%). Gender, smoking, and obesity, as well as axilla and buttock lesions, were risk factors for severe HS, with no differences between ethnicities. No differences were documented in comorbidities and in response to adalimumab, with a high overall response rate of 83%.

CONCLUSIONS

Our findings revealed differences between Arab and Jewish patients with HS in terms of incidence and gender predominance, while no differences were documented in comorbidities and response to adalimumab.

Current Medical and Surgical Treatment of Hidradenitis Suppurativa-A Comprehensive Review

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease presenting with recurrent inflammatory lesions in intertriginous body regions. HS has a pronounced impact on patients' quality of life and is associated with a variety of comorbidities. Treatment of HS is often complex, requiring an individual approach with medical and surgical treatments available. However, especially in moderate-to-severe HS, there is an urgent need for new treatment approaches. In recent years, increased research has led to the identification of new potential therapeutic targets. This review aims to give a comprehensive and practical overview of current treatment options for HS. Furthermore, the clinically most advanced novel treatment approaches will be discussed.

Surgical Treatment in Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic, progressive inflammatory disorder of follicular occlusion with pubertal onset that presents as painful inflammatory nodules, sinus tracts, and tunnelling in apocrine-gland-rich areas, such as the axilla, groin, lower back, and buttocks. The disease course is complicated by contractures, keloids, and immobility and is often associated with a low quality of life. It is considered a disorder of follicular occlusion with secondary inflammation, though the exact cause is not known. Management can often be unsatisfactory and challenging due to the chronic nature of the disease and its adverse impact on the quality of life. A multidisciplinary approach is key to prompt optimal disease control. The early stages can be managed with medical treatment, but the advanced stages most likely require surgical intervention. Various surgical options are available, depending upon disease severity and patient preference. In this review an evidence-based outline of surgical options for the treatment of HS are discussed. Case reports, case series, cohort studies, case-control studies, and Randomized Clinical Trials (RCT)s available in medical databases regarding surgical options used in the treatment of HS were considered for the review presented in a narrative manner in this article.

Systematic Review of Complications and Recurrences After Surgical Interventions in Hidradenitis Suppurativa

BACKGROUND

The possible connection between hidradenitis suppurativa (HS) patients undergoing surgery and higher complications/recurrences has been implied, but inconsistent results reported.

OBJECTIVE

To assess the complication and recurrence rates for HS patients undergoing surgery and to evaluate whether known HS comorbidities and habits (smoking, obesity and diabetes) have an effect on the complication and recurrence rates.

MATERIALS AND METHODS

A systematic review was conducted by 2 reviewers. PubMed and Embase were searched using a predefined search string created in collaboration between the authors and a librarian on January 23, 2019.

RESULTS

Of the 271 references in the original search, 54 relevant articles were identified. This systematic review indicates an overall mean complication rate of 24% and a mean recurrence rate of 20.1% for HS patients undergoing surgery.

CONCLUSION

No significant association between the known surgical risk factors and surgical complications-or recurrence rates in this patient group was found. This review revealed a lack of quality and quantity data in studying the complications/recurrences. The heterogeneity of the studies created limitations, and the presented mean complication/recurrence rates should be interpreted with the consequences thereof. It elucidates the need for better studies and a necessity for a standardized definition of postsurgical HS recurrence.

Laser and Light-Based Treatment Modalities for the Management of Hidradenitis Suppurativa

Hidradenitis suppurativa is a chronic inflammatory skin disease characterized by inflammatory nodules, abscesses, and sinus tracts in intertriginous areas that has a significant impact on patient quality of life. Treatments range from topical, intralesional, systemic, and surgical. Furthermore, laser and light-based treatment options have become increasingly popular because of the limitations of adverse effects associated with systemic therapy and decreased down-time associated with laser and light therapy. These modalities are thought to work through a variety of mechanisms including decreasing inflammation, destroying hair follicles, targeting sebaceous glands, killing bacteria, and debulking lesions through ablation. This review explores these laser and light-based treatment modalities for the treatment of hidradenitis suppurativa.

Hidradenitis suppurativa

Hidradenitis suppurativa (HS; also designated as acne inversa) is a chronic inflammatory disorder, which affects the intertriginous skin and is associated with numerous systemic comorbidities. The estimated prevalence of HS is ~1% in most studied countries. Typically starting in early adulthood, cutaneous inflamed nodules, abscesses and pus-discharging tunnels develop in axillary, inguinal, gluteal and perianal body sites. The comorbidities of HS include metabolic and cardiovascular disorders, which contribute to reduced life expectancy. A genetic predisposition, smoking, obesity and hormonal factors are established aetiological factors for HS. Cutaneous changes seem to start around hair follicles and involve activation of cells of the innate and adaptive immune systems, with pivotal roles for pro-inflammatory cytokines such as tumour necrosis factor, IL-1β and IL-17. The unrestricted and chronic immune response eventually leads to severe pain, pus discharge, irreversible tissue destruction and scar development. HS has profound negative effects on patients' quality of life, which often culminate in social withdrawal, unemployment, depression and suicidal thoughts. The therapeutic options for HS comprise antibiotic treatment, neutralization of tumour necrosis factor and surgical intervention together with lifestyle modification. Nevertheless, there is an enormous need for awareness of HS, understanding of its pathogenesis and novel treatments.

North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations: Part I: Diagnosis, evaluation, and the use of complementary and procedural management

Hidradenitis suppurativa is a chronic inflammatory disorder affecting hair follicles, with profoundly negative impact on patient quality of life. Evidence informing ideal evaluation and management of patients with hidradenitis suppurativa is still sparse in many areas, but it has grown substantially in the last decade. Part I of this evidence-based guideline is presented to support health care practitioners as they select optimal management strategies, including diagnostic testing, comorbidity screening, and both complementary and procedural treatment options. Recommendations and evidence grading based on the evidence available at the time of the review are provided.

Treatments for hidradenitis suppurativa

Hidradenitis suppurativa (HS) is not easily treated. Although not uncommon, HS is often misdiagnosed outside specialized clinics and inappropriately treated as a simple boil or abscess. In recent years, guidelines have been developed on the basis of expert opinion and the available literature. A multifaceted approach is necessary as HS lesions include both inflammation (amenable to medical treatment) as well as fibrosis (amenable to surgery only). The recommended antiinflammatory therapies encompass both antimicrobials and regular anti-inflammatory drugs. We have, therefore, reviewed treatments with the following agents: clindamycin, tetracycline, rifampicin, ertapenem, dapsone, triamcinolone, infliximab, adalimumab, and anakinra. The development of new medical treatments, however, is an ongoing effort, and important new data have been presented since the publication of the guideline. The current approach to the management of fibrotic lesions is surgery. It is important, as manifest fibrosis is generally not susceptible to medical treatment. Here minor excision, carbon dioxide-laser, and major surgery are discussed, and current evidence supporting their use is provided. A comprehensive three-pronged approach with adjuvant therapy, medical therapy, and surgery is recommended. The importance of adjuvant therapy, that is, pain management, wound care, and attention, is stressed. Adjuvant therapy not only plays a major role in patients' perception of a successful treatment but also is of practical importance to their coping and self-management. HS presents a significant unmet need, and this review provides a mechanistic update on the current real-world therapeutic option for the management of this distressing disease.

Hidradenitis Suppurativa

Background:

Hidradenitis suppurativa is a clinically defined disease that causes considerable morbidity for patients. The results of recent studies, which have increased the understanding of this disease, are reviewed.

Objective:

The epidemiology, risk factors, pathogenesis, and treatment of this disease are summarized to help clinicians with practical patient management.

Conclusion:

Hidradenitis suppurativa remains a clinical challenge to patients and physicians alike. Physicians should be familiar with the impact this disease has on the patient and with the range of treatments available. Use of simple incisions as treatment is strongly discouraged. Additional pathogenic as well as therapeutic studies are necessary.

What happens after a single surgical intervention for hidradenitis suppurativa? A retrospective claims-based analysis

Objective Hidradenitis suppurativa (HS) is often treated by surgery. The risk of recurrence after surgery is common and the consequences are substantial, but neither has been quantified using a claims database. This study aimed to estimate the burden associated with non-curative surgery in HS patients. Methods A retrospective analysis was performed of health insurance claims data from Q1 1999 to Q2 2011 in a US claims database. The analysis included 2668 adults with ≥1 diagnosis of HS and ≥1 claim for skin surgery within 6 months after diagnosis. Healthcare resource utilization and medical costs were compared using multivariate regressions. Results Overall, 46% of HS patients had ≥1 indicator of non-curative surgery. The incidences of inpatient, emergency department, and outpatient visits were 88%, 40%, and 30% higher, respectively, for patients with non-curative surgery vs patients without indicator of non-curative surgery (all p < 0.001). Average medical costs were $11,858 and $6427 for patients with and without indicators of non-curative surgery, respectively. The difference of $4185 (p < 0.001) was mainly driven by inpatient costs (difference = $2685; p < 0.001). Limitations Indicators of non-curative HS surgery were defined based on an empirical algorithm. Conclusions Non-curative HS surgery occurred in almost half of all cases and represents a significant burden on patients and payers in terms of resource utilization and costs.

New and traditional surgical approaches to hidradenitis suppurativa

When the prevention of new lesions fails and when medical therapy of established and growing lesions is ineffective, surgery is the accepted method of dealing with hidradenitis suppurativa/acne inversa. The rationale and preferred techniques of mini-unroofing using a biopsy punch, deroofing using scissors, electrosurgery or laser, and classical wide excision and closure are discussed. The situation in which incision and drainage is considered for temporary pain relief would be best considered an opportunity for deroofing, as illustrated in the accompanying online videos.

Hidradenitis Suppurativa: A Guide for the Practicing Physician

Hidradenitis suppurativa is a chronic inflammatory disease of apocrine gland-bearing skin. Although immunologic derangements, genetic predisposition, obesity, and smoking are likely important factors, the pathogenesis of the disease and the effect of available treatments on disease course have not been fully elucidated. In the absence of proper treatment, chronic inflammation results in diffuse scarring and a wide array of complications, including the development of cutaneous squamous cell carcinoma. This severe and chronic disease can have detrimental effects on self-esteem and quality of life. No ideal treatment regimen has been defined, but several therapies have been found to reduce lesion severity and improve symptoms. We reviewed the literature through July 2014 for existing treatments. Published articles were obtained via systematic review of medical databases (PubMed, Embase, Google Scholar) and scrutiny of citation lists using the search terms "hidradenitis suppurativa" and "acne inversa". Given the scarce literature on treatment strategies, we also reviewed data from any case reports or prospective and retrospective studies that were located. On the basis of the existing literature, we provide an evidence-based algorithm for the management of this disease in the primary care setting. More research is needed to evaluate the comparative effectiveness of topical and systemic treatments and to better understand the pathogenesis, natural history, and subtypes of hidradenitis suppurativa.

Lasers and Intense Pulsed Light Hidradenitis Suppurativa

Lasers and intense pulsed light (IPL) treatment are useful for the treatment of hidradenitis suppurativa (HS). Carbon dioxide lasers are used for cutting or vaporization of the affected area. It is a effective therapy for the management of severe and recalcitrant HS with persistent sinus tract and scarring, and can be performed under local anesthesia. HS has a follicular pathogenesis. Lasers and IPL targeting the hair have been found useful in treating HS by reducing the numbers of hairs in areas with HS. The methods have few side effects, but the studies are preliminary and need to be repeated.

Recurrence rate and patient satisfaction of CO2 laser evaporation of lesions in patients with hidradenitis suppurativa: a retrospective study

BACKGROUND

Hidradenitis suppurativa (HS) is a debilitating disease and is difficult to treat. Validation of surgical techniques is therefore of great importance in the management of HS. Carbon dioxide (CO2) laser evaporation has been shown effective, but larger-scale studies are scarce.

OBJECTIVE

To determine the recurrence rate, time to recurrence, and factors influencing disease recurrence in skin treated with CO2 laser evaporation, and healing by secondary intention; and patients' satisfaction with treatment.

METHODS

Fifty-eight patients treated with CO2 laser evaporation were interviewed regarding recurrence and satisfaction after a mean of 25.7 months.

RESULTS

Seventeen of 58 (29%) reported recurrence of HS lesions within the borders of the treated areas after a mean of 12.7 months. Obesity was a risk factor for recurrence with a hazard ratio of 4.53. Fifty-five patients (95%) reported some or great improvement, and 91% would recommend the CO2 laser surgery to other HS patients.

CONCLUSION

This study supports the claim that CO2 laser treatment is an effective modality for recurrent HS lesions in a majority of patients. The authors identified obesity as a risk factor for recurrence. Self-reported satisfaction is high, and only 3 of 58 report no change in the condition. None reported a worsening.

The medical and laser management of hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic, debilitating skin disease characterized by painful recurrent nodules and abscesses. In advanced stages, sinus tracts form, with resulting fibrotic and cribriform scar formation, leading to dermal contractures and induration of the affected skin. The epidemiology of HS is poorly described, and few population-based studies exist. The reported incidence varies from 0.0003 to 4%. Effective treatment options for HS are limited, and randomized controlled trials addressing the safety and/or efficacy of available treatments are scarce. No medical treatment to date has been approved by the US FDA specifically for the treatment of HS. While some evidence of disease improvement exists with agents including clindamycin and rifampicin, metformin, fumarates, infliximab, and adalimumab, no single treatment has shown overwhelmingly positive outcomes. The lack of randomized controlled trials for most treatments and often disappointing treatment outcomes is disheartening. This study reviews the published evidence for treatment options for HS.

European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa

Hidradenitis suppurativa/acne inversa (HS) is a chronic, inflammatory, recurrent, debilitating skin disease of the hair follicle that usually presents after puberty with painful, deep-seated, inflamed lesions in the apocrine gland-bearing areas of the body, most commonly the axillae, inguinal and anogenital regions. A mean disease incidence of 6.0 per 100,000 person-years and an average prevalence of 1% has been reported in Europe. HS has the highest impact on patients' quality of life among all assessed dermatological diseases. HS is associated with a variety of concomitant and secondary diseases, such as obesity, metabolic syndrome, inflammatory bowel disease, e.g. Crohn's disease, spondyloarthropathy, follicular occlusion syndrome and other hyperergic diseases. The central pathogenic event in HS is believed to be the occlusion of the upper part of the hair follicle leading to a perifollicular lympho-histiocytic inflammation. A highly significant association between the prevalence of HS and current smoking (Odds ratio 12.55) and overweight (Odds ratio 1.1 for each body mass index unit) has been documented. The European S1 HS guideline suggests that the disease should be treated based on its individual subjective impact and objective severity. Locally recurring lesions can be treated by classical surgery or LASER techniques, whereas medical treatment either as monotherapy or in combination with radical surgery is more appropriate for widely spread lesions. Medical therapy may include antibiotics (clindamycin plus rifampicine, tetracyclines), acitretin and biologics (adalimumab, infliximab). A Hurley severity grade-relevant treatment of HS is recommended by the expert group following a treatment algorithm. Adjuvant measurements, such as pain management, treatment of superinfections, weight loss and tobacco abstinence have to be considered.

Skin-Tissue-sparing Excision with Electrosurgical Peeling (STEEP): a surgical treatment option for severe hidradenitis suppurativa Hurley stage II/III

BACKGROUND

Surgery is the only curative treatment for removal of the persistent sinus tracts in the skin that are characteristic of severe hidradenitis suppurativa (HS). Complete resection of the affected tissue by wide excision is currently regarded as the preferred surgical technique in these cases. However, relatively large amounts of healthy tissue are removed with this method and suitable skin-tissue-saving techniques aiming at creating less-extensive surgical defects are therefore needed in severe HS.

METHOD

We describe a skin-tissue-saving surgical technique for HS Hurley stage II-III disease: the Skin-Tissue-sparing Excision with Electrosurgical Peeling (STEEP) procedure.

DISCUSSION

In contrast to wide excisions that generally reach into the deep subcutaneous fat, the fat is maximally spared with the STEEP procedure by performing successive tangential excisions of lesional tissue until the epithelialized bottom of the sinus tracts has been reached. From here, secondary intention healing can occur. In addition, fibrotic tissue is completely removed in the same manner as this also serves as a source of recurrence. This tissue-sparing technique results in low recurrence rates, high patient satisfaction with relatively short healing times and favourable cosmetic outcomes without contractures.

Residual scarring from hidradenitis suppurativa: fractionated CO2 laser as a novel and noninvasive approach

Hidradenitis suppurativa (HS) is a chronic, relapsing, inflammatory skin condition that can have a significant psychosocial impact, both with the active disease and with residual scarring. Although a wide variety of treatment options exist for HS, to our knowledge there are no reported modalities aimed specifically at treating HS scarring. We describe the case of an adolescent female who received medical management of intramammary HS followed by successful treatment with fractionated 10,600-nm carbon dioxide laser for her residual cribriform scarring. We believe there is great potential for the use of fractionated carbon dioxide laser to improve short- and long-term psychosocial outcomes of HS, promote physical scar remodeling, and possibly alter the disease process itself.

A double-blind placebo-controlled randomized trial of adalimumab in the treatment of hidradenitis suppurativa

BACKGROUND

Hidradenitis suppurativa (HS) has an impact on patients' quality of life. Treatment of HS is generally unsatisfactory, thus new treatments are needed.

OBJECTIVES

To test the efficacy of adalimumab in HS.

METHODS

This was a prospective, randomized, double-blinded, placebo-controlled, two-centre clinical trial conducted in Denmark. Inclusion criteria were age above 18 years and a clinical diagnosis of moderate to severe HS defined as Hurley stage II or III for at least 6 months. The patients were randomized 1:2 (placebo/active). Actively treated patients received adalimumab 80 mg subcutaneously (s.c.) at baseline followed by 40 mg s.c. every other week for 12 weeks. Placebo-treated patients received identical-looking injections with no active ingredient. The medicine was dispensed in sequentially numbered computer-randomized containers. Participants, care givers and those assessing the outcomes were blinded to group assignment. The primary efficacy endpoints were changes in the HS scores (Sartorius and Hurley scoring systems). Secondary efficacy endpoints included changes in pain (visual analogue scale), days with lesions and Dermatology Life Quality Index, and evaluation of scarring. Recruitment was terminated early due to expiry date of trial medication.

RESULTS

Twenty-one patients were included, of whom 15 received adalimumab and six received placebo. All participants were analysed according to the intention to treat principle. A significant reduction was seen in Sartorius score after 6 weeks and an almost significant reduction was seen after 12 weeks of active treatment (-10·7 vs. 7·5, P = 0·024 and -11·3 vs. 5·8, P = 0·07) when compared with the placebo group.

CONCLUSIONS

A significant reduction in HS severity was gained after 6 weeks. No long-term curative effect was uniformly seen.

Hidradenitis suppurativa: a review of cause and treatment

PURPOSE OF REVIEW

Hidradenitis suppurativa is a chronic or relapsing inflammatory cutaneous disorder manifested by recurrent formation of abscesses, fistulating sinus and scarring in the apocrine-gland-bearing skin. This review discusses the different aetiological theories and management opportunities.

RECENT FINDINGS

Current understanding of the pathogenesis suggests that hyperkeratosis of the infundibulum, leading to follicular occlusion of the pilosebaceous unit plays a role. Bacterial infection with staphylococci, Escherichia coli and streptococcus is considered as a secondary event in the pathogenesis. Smoking and obesity are both known as risk factors and are associated with more severe disease course. Recently, more attention has been put into the understanding of the immunopathology of the skin and the results indicate that hidradenitis suppurativa may be considered as an inflammatory disease of unknown cause based on a defect in the hair follicle immunity. The treatments are most appropriately chosen on the basis of disease severity and the existence of any associated risk factors or comorbidities. There are three levels in the management of hidradenitis suppurativa: topical options, systemic options and surgical methods including laser therapy. At each level several treatment principles have shown themselves to be efficient, and may therefore be used either alone or in combination. Therapies are generally effective against microorganisms, inflammation or infundibular hyperkeratosis. Where an antimicrobial therapy is used, the drugs used often have significant additional immunomodulatory effects.

SUMMARY

The recent studies give us a better insight into the pathogenesis of hidradenitis suppurativa and should translate into improved therapies.

Sequential therapy for gonococci inflammation of paraurethral glands in males

OBJECTIVE

To approach the method of sequential therapy in gonococcal inflammation of the paraurethral glands around the external urethral orifice in males.

METHODS

Step one: ceftriaxone sodium (1 g intramuscularly (IM) once daily for 5 days) was used for all patients. Step two: refractory patients from step one were treated with incision and drainage, followed by administration of IM ceftriaxone sodium. Step three: patients' sinus tracts were cauterized with a monopulse CO(2) laser.

RESULTS

After step one, 34 patients recovered (recovery rate 70.83%). However, 14 patients were unaffected, and sinus tracts appeared in two patients. After step two, 11 of 14 patients recovered and three patients developed sinus tracts, two of whom had sinus tracts in step one that did not heal in step two. After step three, all patients with sinus tracts that had been treated with monopulse CO(2) laser therapy recovered in 2 weeks.

CONCLUSION

This sequential therapy can be used to successfully treat gonococcal inflammation of the paraurethral glands around the external urethral orifice in males.

Prospective controlled clinical and histopathologic study of hidradenitis suppurativa treated with the long-pulsed neodymium:yttrium-aluminium-garnet laser

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic inflammatory disease involving the intertriginous areas.

OBJECTIVE

We sought to conduct clinical and histopathologic evaluation of the efficacy of long-pulsed neodymium:yttrium-aluminium-garnet laser treatment for HS.

METHODS

We conducted a prospective, randomized, right-left within-patient controlled trial for HS (n = 22). Four monthly laser sessions were performed. Disease activity was measured at baseline, and treatment response was assessed before each laser session and monthly for 2 months after the completion of laser treatment, using a modified scoring system based on Sartorius score. Histologic examination was performed at baseline, immediately after laser treatment, and at 1 and 4 weeks after treatment. A patient questionnaire was circulated on the last visit to assess patients' level of satisfaction.

RESULTS

There was progressive improvement in disease activity, most significantly during the 4 months of treatment, which was maintained during the 2-month posttreatment follow-up period. Averaged over all anatomic sites, the percent improvement was 72.7% on the laser treated side, and 22.9% on the control side (P < .05). Histologic examination showed an initial acute neutrophilic infiltrate. Granulomatous inflammation was present on follow-up biopsy specimens 4 weeks later. An inflammatory infiltrate surrounded the hair shaft remnants, denoting destruction of hair follicles.

LIMITATIONS

Small sample size was a limitation.

CONCLUSIONS

Long-pulsed neodymium:yttrium-aluminium-garnet laser, together with topical benzoyl peroxide and clindamycin, is significantly more effective than topical benzoyl peroxide and clindamycin alone for the treatment of HS. Preliminary review of histopathology suggests the mechanism of action is destruction of the hair follicle. The overall success of the treatment in both clearing pre-existing lesions and preventing new eruptions, coupled with high patient satisfaction, makes the neodymium:yttrium-aluminium-garnet laser a promising treatment advance for this highly disabling condition.

[Acne inversa]

Acne inversa is a chronic inflammatory disease of the hair follicles. It can lead to severe functional and psychological impairment. It is characterized by inflamed painful nodules, abscesses, fistulas and scarring in late stages of the disease. The causes of acne inversa are still not fully understood. Conservative treatment options such as antibiotics may lead to clinical improvement; however they do not produce healing. Therapy of choice, especially in severe forms, is radical wide excision of all affected areas. Despite a variety of treatment options, acne inversa is still a therapeutic challenge.

Hidradenitis suppurativa: successful treatment using carbon dioxide laser excision and marsupialization

BACKGROUND

Hidradenitis suppurativa (HS) is a disease associated with significant patient morbidity and less-than-ideal therapies.

OBJECTIVES

To determine the long- and short-term benefits of carbon dioxide (CO(2)) laser excision and marsupialization in the management of persisent lesions of HS.

METHODS

Patients with long-standing lesions of HS were treated using a CO(2) laser to excise inflammatory and draining masses.

RESULTS

One hundred eighty-five areas were treated in 61 patients using the CO(2) laser excision and marsupialization technique in 154 sessions. Local anesthesia was used for all but three sessions. Healing occurred primarily through secondary intention. In follow-up from 1 to 19 years, acceptable to excellent qualities of healing occurred. Recurrence within the treated area occurred in two of 185 sites treated.

CONCLUSION

CO(2) laser excision and marsupialization appears to be an effective therapy for management of persisent or late-stage HS. There was good patient comfort during and after treatment, lower costs than with inpatient modalities, good healing, and minimal risk of recurrence within the treated areas.

Hidradenitis suppurativa

Hidradenitis suppurativa is a chronic disease characterized by recurrent, painful, deep-seated, rounded nodules and abscesses of apocrine gland-bearing skin. Subsequent suppuration, sinus tracts and hypertrophic scarring are its main features. Onset is usually after puberty, although it is most common during the third decade and may persist in old age. The disease tends to be chronic and may develop to subcutaneous extension leading to indurations, sinus, and fistula having a profound impact on the quality of life. The prevalence is 1% in several studies. Axillary and inguinal involvement is more common in females; peri-anal and buttocks localizations are prevalent in males. The exact aetiology remains unknown. The primary event is a follicular occlusion with secondary inflammation, infection and destruction of the pilo-sebaceo-apocrine apparatus and extension to the adjacent sub-cutaneous tissue. Infection is common. Smoking may be a triggering factor. Obesity aggravates the discomfort. Differential diagnostic includes Crohn's disease, nodular acne and furonculosis. The main complications are arthropathy, carcinoma. Treatment depends upon the stage of the disease. Early nodular lesions may be treated by antibiotics for acute stage; long-term antibiotics, zinc salts may be useful as maintenance treatment; anti-TNF drugs have been used in severe cases; systemic steroids, estrogens, anti-androgens, retinoids have been used as options with limited success. Surgical treatment includes incision with or without drainage for limited abscesses; limited excisions are used for locally recurring draining sinuses. Total wide excision and healing with secondary intention or flaps and grafts is the only curative procedure in case of advanced disease.

Randomized control trial for the treatment of hidradenitis suppurativa with a neodymium-doped yttrium aluminium garnet laser

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic suppurative condition for which there is limited efficacy of medical and surgical treatments.

OBJECTIVE

To assess whether the 1,064-nm neodymium-doped yttrium aluminium garnet (Nd:YAG) laser is an effective treatment for HS.

MATERIALS AND METHODS

Prospective, randomized, controlled study for patients with stage II to III HS disease (n=22). A series of 3 monthly laser sessions were performed. Treatment response was measured before each laser session and 1 month after the completion of laser treatment (HS Lesion, Area, and Severity Index (HS-LASI) scale). A modification was made to include symptoms (erythema, edema, pain, and purulent discharge; modified HS-LASI, 0-3 scale).

RESULTS

The percentage change in HS severity after 3 months of treatment was -65.3% over all anatomic sites, -73.4% inguinal, -62.0% axillary, and -53.1% inframammary. For all anatomic sites combined and each individual anatomic site, the change in HS severity from baseline to month 3 was statistically significant at the treated sites (p<.02 for modified HS-LASI and HS-LASI) but not at the control sites (p>.05 for modified HS-LASI and HS-LASI).

CONCLUSIONS

The long-pulse Nd:YAG laser is effective for treatment of HS. The effectiveness of Nd:YAG laser, a hair epilation device, supports the primary follicular pathogenesis of the condition.

Hidradenitis suppurativa

Background

Hidradenitis suppurativa is a chronic, recurrent, suppurative cutaneous disease. Despite its incidence, optimal medical or surgical treatment remains unclear. This review describes the disease, ranging from pathogenesis to treatment and prognosis.

Methods

Articles were sourced from PubMed and Medline, using the MeSH terms ‘hidradenitis suppurativa’ and ‘acne inversa’. Selection of articles was based on peer review, journal, relevance and English language.

Results and conclusion

On the basis of histological findings, the disease is now considered inflammatory and originating from the hair follicle; therefore, the term ‘acne inversa’ is favoured by some experts. The exact aetiology remains obscure but smoking seems to be a major triggering factor. Treatment should be individualized according to the site and extent of the disease. Absolute cessation of smoking is essential in the treatment of hidradenitis. Management with antibiotics or other medications may relieve early symptoms, but radical surgery may be necessary for control and to prevent recurrence.

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.