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.

Efficacy and safety of a combined pharmacological and surgical approach in patients affected by hidradenitis suppurativa: data from a retrospective real-world clinical study.

BACKGROUND: Hidradenitis suppurativa (HS) is a debilitating chronic skin disease; its therapeutic approach often requires combined medical and surgical treatment. METHODS: The aim of this study was to assess the efficacy and safety of the surgical approach combined with different pharmacological treatments, evaluating the proportion of patients achieving the hidradenitis suppurativa clinical response (HiSCR), along with the incidence of postoperative complications, and local recurrence. A retrospective study of HS patients (Hurley I-III) presenting at least one skin lesion requiring surgery was performed. Demographic and clinical data were collected (kind and anatomical location of lesion excised, type of surgical procedure). Further data included: Hurley stage and IHS4 at baseline and week 16, HiSCR at week 16 after surgery, ongoing therapy at the time of surgery (topical, systemic antibiotic, biologics), postoperative complications and local recurrence at week 16. RESULTS: Forty-two patients with female predominance (66.7%, 28/42), with a mean age of 30.3 (SD±10.5) years, were enrolled. At week 16, 53% of patients achieved HiSCR, with baseline Hurley III inversely related to HiSCR achievement (P<0.05). No increased incidence of postoperative complications was detected. Three cases of local recurrence were reported at week 16. CONCLUSIONS: The results support the efficacy and safety of the combined therapy in the management of HS; no increased risk of complications emerged among patients concomitantly treated with biologics, compared to those on conventional systemic therapy or exclusively treated with surgery.

Deroofing: A safe, effective and well-tolerated procedure in patients with hidradenitis suppurativa.

INTRODUCTION: Hidradenitis suppurativa (HS) is a recurrent, debilitating, chronic disorder of the pilosebaceous unit. Although advances in HS treatment have been made, more than 45% of patients remain dissatisfied with systemic treatment, and more than one-third are dissatisfied with surgical procedures. OBJECTIVES: A prospective, observational study on the deroofing procedures in HS with special attention paid to patient satisfaction and complications. METHODS: HS lesions were assessed clinically and by the use of ultrasound. Patients reported outcomes, including pain, itch and satisfaction, were measured at 24 h post-surgery by a numeric rating scale (NRS) ranging from 0 to 10. Additionally, the timeline of objective wound closure reported by patients in (weeks), in addition to the need for any analgesics use, were both evaluated. RESULTS: The mean closure time of the post-deroofing wound was assessed as 4.4 ± 1.9 weeks. A statistically longer time was necessary for complete closure in males than in females (4.9 ± 2.2 weeks and 3.9 ± 1.6 weeks, respectively; p = 0.046). The closure time correlated positively yet weakly with the HS tunnel's width (r = 0.27, p = 0.016) and length (r = 0.228, p = 0.044). Patients assessed mean pain at 24 h post-op as mild with 0.7 ± 1.2 points according to NRS, with no differences between sexes. Similarly, itch in the first 24 h was assessed as mild with 1.8 ± 1.1 points, without differences between sexes. No pain, itch or adverse events were reported after 1 week following deroofing. Moreover, no cases of wound infection were reported. An overall patient satisfaction was assessed as 9.9 ± 0.4 points (range 9-10 points). CONCLUSION: Deroofing is an easy, effective and safe dermatosurgical procedure that does not require surgical experience or operating theatre. It is associated with no complications and very low post-op pain and should be part of holistic HS management.

Pedicled circumflex scapular artery perforator flap with intra-axillary tunneling for axillary defect coverage after surgical excision of hidradenitis suppurativa: A case report and literature review.

Axillary defects represent a rather common issue in plastic surgery practice. Surgical resections related to skin disease are frequent in this region and their extension often requires soft tissue transfer for coverage. In this setting, locoregional pedicled flaps are usually preferred. The nearby tissues offer pliable but still resistant skin, which satisfy the "like-with-like" reconstructive principle. Over the years different procedures have been described for this purpose. Among them, a valuable and often underestimated technique is the circumflex scapular artery perforator flap (CSAP). This technique might be particularly suitable for thin but relatively large defects. Its main advantages are a low donor site morbidity, a very reliable anatomy, and a perforator pedicle able supply a large skin paddle. In the present work, we report the use of a pedicled vertical CSAP flap passed through the axillary canal in order to cover a 9 cm × 7 cm axillary defect after surgical excision of hidradenitis suppurativa resistant to conservative treatment. The perforator-based pedicled presented two branches, which allowed us to harvest safely a large skin paddle, which limited its range of motion. For this reason, we opted for a passage through the axillary canal for the flap inset. The postoperative course was uneventful and full shoulder range of motion was obtained at 3 months follow-up. Despite most of the descriptions of this flap available so far showed its employment for limb's reconstructions, we believe that it is a very useful tool also for locoregional coverage. Moreover, the unconventional passage below the axillary muscles allowed reaching the recipient site even with a shorter pedicle, such as the one encountered in this case.

Treatment of Hidradenitis Suppurativa Evaluation Study (THESEUS): a prospective cohort study.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic, painful disease affecting flexures and other skin regions, producing nodules, abscesses and skin tunnels. Laser treatment targeting hair follicles and deroofing of skin tunnels are standard HS interventions in some countries but are rarely offered in the UK. OBJECTIVES: To describe current UK HS management pathways and influencing factors to inform the design of future randomized controlled trials (RCTs). METHODS: THESEUS was a nonrandomized 12-month prospective cohort study set in 10 UK hospitals offering five interventions: oral doxycycline 200 mg daily; oral clindamycin and rifampicin both 300 mg twice daily for 10 weeks, extended for longer in some cases; laser treatment targeting hair follicles; deroofing; and conventional surgery. The primary outcome was the combination of clinician-assessed eligibility and participant hypothetical willingness to receive each intervention. The secondary outcomes were the proportion of participants selecting each intervention as their final treatment option; the proportion who switch treatments; treatment fidelity; and attrition rates. THESEUS was prospectively registered on the ISRCTN registry: ISRCTN69985145. RESULTS: The recruitment target of 150 participants was met after 18 months, in July 2021, with two pauses due to the COVID-19 pandemic. Baseline demographics reflected the HS secondary care population: average age 36 years, 81% female, 20% non-White, 64% current or ex-smokers, 86% body mass index ≥ 25, 68% with moderate disease, 19% with severe disease and 13% with mild disease. Laser was the intervention with the highest proportion (69%) of participants eligible and willing to receive treatment, then deroofing (58%), conventional surgery (54%), clindamycin and rifampicin (44%), and doxycycline (37%). Laser was ranked first choice by the greatest proportion of participants (41%). Attrition rates were 11% and 17% after 3 and 6 months, respectively. Concordance with doxycycline was 52% after 3 months due to lack of efficacy, participant choice and adverse effects. Delays with procedural interventions were common, with only 43% and 26% of participants starting laser and deroofing, respectively, after 3 months. Uptake of conventional surgery was too small to characterize the intervention. Switching treatment was uncommon and there were no serious adverse events. CONCLUSIONS: THESEUS has established laser treatment and deroofing for HS in the UK and demonstrated their popularity with patients and clinicians for future RCTs.

Use of multiple fasciocutaneous flaps for the management of extensive hidradenitis suppurativa.

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease with a relapsing nature that has a significant impact on the patient's quality of life. The clinical presentation of the disease includes deep dermal abscesses and sinus tracts. Long-term affliction of the disease may lead to contractures, scars and fibrosis. Management is still challenging and varies from medical to surgical options. We report the following case of a man in his 30s who presented with severe HS in the axillae, groins, perineum and lower sacral region. The patient has been treated by excision of the whole lesions followed by using multiple fasciocutaneous flaps as a reconstructive method.

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.

The Treatment of Hidradenitis Suppurativa Evaluation Study introduced deroofing of skin tunnels and laser treatment for hidradenitis suppurativa and found that these are preferred interventions for future trials compared with oral antibiotics or conventional surgery.

A Retrospective Review of Laser Therapy for Treatment of Hidradenitis Suppurativa.

PURPOSE: Hidradenitis suppurativa (HS) is a chronic inflammatory disease characterized by painful and foul-smelling cystic nodules and sinus tracts in the apocrine gland-bearing regions. The treatment options include topical, intralesional, systemic, and surgical modalities. Currently, the most novel therapy is laser therapy to provide localized treatment without systemic adverse effects. However, data regarding patient outcomes after laser treatment are limited because of the low prevalence of this disease. This study aimed to evaluate the efficacy of laser therapy as a treatment modality for patients with HS. METHODS: A retrospective review cohort analysis of patients with HS undergoing laser treatment between 2016 and 2021 was conducted. Patient demographics, lesion location(s), Hurley stage, age of onset and diagnosis, treatment length, type, outcomes, and complications were analyzed. RESULTS: Ninety-four patients met the inclusion criteria; on average, patients were treated with 5.8 laser sessions for 14.8 months with no complications and minor blood loss. Hidradenitis suppurativa progression commonly starts during puberty, with a median onset of 13.8 years and diagnosis of HS at 16.2 years. All patients (n = 94) showed an improvement in HS disease severity: 59.6% completed treatment, 12.0% are currently undergoing treatment, and 26.0% were lost to follow-up. CONCLUSIONS: Laser therapy is an effective and safe therapy for HS leading to improved quality of life and should be considered in the treatment and management of HS.

LOSS OF EFFICACY OF ADALIMUMAB IN HIDRADENITIS SUPPURATIVA: FOCUS ON ALTERNATIVES.

The loss of efficacy of adalimumab, one of the most commonly used biologics for the treatment of hidradenitis suppurativa/acne inversa, is not news to the scientific community, and it should be noted that the number of cases not responding to this agent has been progressively increasing in recent years. We present a 45-year-old patient with hidradenitis suppurativa/acne inversa (Hurley II-III) with a complaint duration of 3 years who has been on adalimumab 40 mg weekly for 9 months. The lack of improvement in the clinical condition as well as the progression of the disease within the ongoing biologic therapy led to the need for repeated hospitalizations and the additional introduction of intravenous treatment with a regimen of antibiotics (Ertapenem, Metronizadol, Ceftriaxone), zinc, colchicine, and pain relievers. During these hospitalizations, a partial improvement was found, which was not durable and required the parallel administration of antibiotics, colchicine and zinc in combination with adalimumab in an outpatient regimen. Several attempts at surgical treatment/incision in non-specialized units were also made, and these too remained generally unsuccessful or with a nondurable, unsatisfactory clinical outcome. Due to the subsequent consecutive worsening of the symptomatology, the patient was admitted for evaluation of the clinical condition and optimization of treatment. Surgical treatment was performed by surgical deroofing under general anaesthesia, concurrent with discontinuation of adalimumab/antibiotic application and long-term remission was achieved. Surgical deroofing has also been shown to be an effective therapeutic option in the loss/lack of efficacy of adalimumab in patients with hidradenitis suppurativa (Hurley II-III). In the case of therapeutic resistance or worsening of symptomatology in patients with acne inversa within adalimumab therapy, other advanced alternatives such as golimumab, anakinra, etanercept are available. The efficacy of these second-line agents is also questionable due to the development of resistance to them as well, which in turn necessitates the frequent switch to third-line agents such as: Ustekinumab, Tildarkizumab, Certolizumab or Ixekizumab. The future will show to what extent this "trust" could be justified and whether in practice the surgical approach will once again displace the so-called "modern options" as the reasonable next basic and reliable alternative. The disadvantage of modern biological therapy is mainly due to the loss of efficacy/development of resistance over time, multiple side effects and frequent recurrence after discontinuation of treatment. In contrast, in the case of specific, stage-oriented, specialized surgical treatment of hidradenitis suppurativa/ acne inversa, in the form of surgical deroofing, for example, the results are long-lasting and in the case of recurrences: the latter are much more easily managed by dermatosurgery/surgery again. The effect achieved after this type of manipulation is essential for the patients' quality of life and guarantees to a large extent also prevention of the development of keratinocyte tumours in the areas affected by chronic inflammation. Precisely because of the aforementioned facts, in a serious number of patients this type of treatment could be considered as a priority. The rethinking of the guideline and the staging of surgical modalities as first-line therapy could, in a serious number of patients, have a positive effect. Swap for surgery seems to be a good alternative.

What should a surgeon know about hidradenitis suppurativa?

Otherwise known as Verneuil's disease, hidradenitis suppurative (HS) is a severe dermatosis of heterogeneous appearance affecting 1% of the population. Its pathophysiology is multifactorial, involving genetic predisposition, inflammatory disorder and environmental elements. Its diagnosis is based on the association of three clinical characteristics: characteristic lesions, typical localizations, and the chronic and recurrent nature of the lesions. Given its diversified aspects, diagnosis can be difficult to achieve. As its manifestations often include abscesses, it is important for the surgeon to know how to detect this pathology. The development of biologics has improved treatment of this disease, treatment that necessitates a multidisciplinary medical and surgical approach involving dermatologists and proctologists as well as surgeons. The objective of this report is to synthesize what a surgeon will need to know so as effectively treat HS patients.

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.

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 (Sabat et al., 2022). 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.

Hidradenitis suppurativa. A case report.

Hidradenitis suppurativa is a disease with underestimated incidence, consequences and treatment difficulty. Regarded as a minor illness, for the patient it is disabling physically and socially, and for the doctor it is a challenge in choosing the appropriate treatment. We present the case of a 28-year-old man who presented with an advanced and persistent form of hidradenitis treated in a general surgery department. Solving the case combined conservative and surgical treatment (wide excisions, plasties with fasciocutaneous superior gluteal artery perforator flap, thoracodorsal artery perforator flap, free anterolateral thigh flap). This case illustrates the problems raised by a seemingly trivial disease. KEY WORDS: Fasciocutaneous Superior Gluteal Artery Perforator Flap, Follicular Occlusion, Free Anterolateral Thigh Flap, Hidradenitis Suppurativa, Skin Ulcer, Skin Fold, Thoracodorsal Artery Perforator Flap.

The novel use of cryopreserved human allograft in extensive Hurley stage III hidradenitis suppurativa.

INTRODUCTION: HS is a debilitating dermatologic condition in which apocrine sweat glands become occluded, leading to severe inflammation. Treatment usually ranges from conservative management to surgical intervention with the goal of treating existing lesions while reducing the rate of recurrence, progression, and scarring. Depending on the surface area involved, autologous skin grafting may be difficult when donor sites are limited due to the extent of disease, previous surgery, or scarring. This case report examines the efficacy of cryopreserved human allograft as a surgical treatment of extensive HS. CASE REPORT: A 37-year-old man presented with severe, refractory Hurley stage III HS in which cryopreserved human allograft was used to aid in wound contracture and granulation tissue formation. In addition, its use improved contour deformities and served as a bridge to autologous skin grafting, minimizing donor site size and morbidity. CONCLUSIONS: While autologous skin grafting is necessary for final wound closure, the use of cryopreserved human allograft provides biologic wound management that aids as a bridge to autologous skin grafting. As such, the authors advocate its use as a tissue scaffold in the management of severe, extensive HS and other dermatologic conditions requiring skin excision.