Extensive Hidradenitis Suppurativa (Hurley stage III) often requires aggressive surgical management due to widespread involvement and significant morbidity.
1. Radical Excision with Flap Reconstruction
Procedure: Complete removal of affected tissue followed by reconstruction using local, regional, or free flaps.
Efficacy: Low recurrence rates (5-15%). Kagan et al. (2017)* reported a recurrence rate of 12% after radical excision and flap reconstruction.
2. Split-Thickness Skin Grafting (STSG)
Procedure: Excision of affected tissue followed by coverage with STSG.
Efficacy: Effective for large defects but may have graft failure rates of 10-20%. Mehdizadeh et al. (2015)* found STSG to be a reliable option for large defects, with 85% graft survival.
Sometime both 1 and 2 options have to be used in very extensive lesions.
3. Healing by Secondary Intention
Procedure: Excision of affected tissue without primary closure, allowing the wound to heal naturally.
Efficacy: Longer healing time but lower recurrence rates (10-20%). Ritz et al. (2018) reported good outcomes with secondary intention healing, particularly in perineal HS.
Surgical Management of Area-Specific Disease
Axilla
Wide local excision with rotational flaps and /0r skin grafting, deroofing, or CO2 laser (for small area). Recurrence rates of 10-25% after wide excision. Alharbi et al. (2012)* found that wide excision with primary closure had a recurrence rate of 15% in axillary HS.
Inguinal Area
Options: Radical excision with STSG or flap reconstruction.
Efficacy: Recurrence rates of 10-30%. Kagan et al. (2017)* reported a 20% recurrence rate after flap reconstruction in the inguinal region.
Perineum
Options: Wide excision with secondary intention healing or STSG.
Efficacy: Recurrence rates of 15-25%. Ritz et al. (2018)* found secondary intention healing to be effective in perineal HS, with low recurrence rates.
Lower Back
Options: Wide excision with primary closure or STSG.
Efficacy: Recurrence rates of 10-20%. Blok et al. (2015)* reported good outcomes with STEEP in lower back HS.
Multisite Disease Surgical Options
Multisite Hidradenitis Suppurativa presents a unique challenge due to the involvement of multiple anatomical regions. A staged surgical approach is often necessary.
Staged Excision
Procedure: Sequential excision of affected areas over multiple surgeries.
Efficacy: Reduces surgical burden and allows for better recovery between procedures. Mehdizadeh et al. (2015) reported improved outcomes with staged excision in multisite disease.
Combination Therapy
Surgical excision combined with medical therapy (e.g., biologics like adalimumab).
Efficacy: Reduces recurrence rates and improves healing. Zouboulis et al. (2016) found that combining surgery with adalimumab reduced recurrence rates by 50%.
Conclusion:
The choice of procedure depends on disease severity, anatomical location, and patient factors. Multisite disease often requires a staged approach, and combining surgery with medical therapy can improve outcomes in selected patients.
