Surgical management of hidradenitis suppurativa (acne inversa)
- Dennis P Orgill, MD, PhD
Dennis P Orgill, MD, PhD
- Associate Professor of Surgery
- Harvard Medical School
- Section Editors
- Marc G Jeschke, MD, PhD
Marc G Jeschke, MD, PhD
- Section Editor — Burn Surgery
- Director Ross Tilley Burn Centre
- Sunnybrook Health Sciences Centre
- Professor, Department of Surgery and Plastic Surgery
- University of Toronto
- Mark V Dahl, MD
Mark V Dahl, MD
- Section Editor — Acne and Rosacea
- Professor Emeritus
- Mayo Clinic College of Medicine
Hidradenitis suppurativa (HS), also known as acne inversa (AI), is a chronic, inflammatory skin disorder of the folliculopilosebaceous units characterized by the development of inflammatory nodules, pustules, sinus tracts (tunnels), and scars, primarily in intertriginous areas. Physical pain, odor, chronic drainage, and disfigurement are common features of this disorder.
The surgical management of hidradenitis suppurativa is reviewed here. The clinical features, diagnosis, and medical management are discussed separately. (See "Hidradenitis suppurativa (acne inversa): Pathogenesis, clinical features, and diagnosis" and "Hidradenitis suppurativa (acne inversa): Treatment".)
In the setting of refractory HS, surgery may be needed to remove active foci of disease and eliminate scarred tissue sequelae . Surgery should not be used in isolation; combining surgery with dietary restrictions and medical therapy provides the best chance for preventing the development of new lesions and controlling disease progress. As surgery is an invasive procedure that will result in additional scarring, prior to proceeding, the risks, benefits, and alternatives should be discussed with the patient.
Surgical procedures may be performed on individual inflammatory nodules, abscesses, or sinus tracts and in severe cases may be necessary to excise an entire affected area . The approach to treating lesions is individualized and becomes more aggressive with higher-stage HS, particularly if medical therapies have not been successful at controlling the disease. (See "Hidradenitis suppurativa (acne inversa): Treatment", section on 'Summary and recommendations'.)
Surgical techniques used to treat HS are listed and discussed in more detail below.
- Kohorst JJ, Baum CL, Otley CC, et al. Surgical Management of Hidradenitis Suppurativa: Outcomes of 590 Consecutive Patients. Dermatol Surg 2016; 42:1030.
- Ellis LZ. Hidradenitis suppurativa: surgical and other management techniques. Dermatol Surg 2012; 38:517.
- Danby FW, Jemec GB, Marsch WCh, von Laffert M. Preliminary findings suggest hidradenitis suppurativa may be due to defective follicular support. Br J Dermatol 2013; 168:1034.
- Mehdizadeh A, Hazen PG, Bechara FG, et al. Recurrence of hidradenitis suppurativa after surgical management: A systematic review and meta-analysis. J Am Acad Dermatol 2015; 73:S70.
- van der Zee HH, Prens EP, Boer J. Deroofing: a tissue-saving surgical technique for the treatment of mild to moderate hidradenitis suppurativa lesions. J Am Acad Dermatol 2010; 63:475.
- Danby FW. Commentary: unroofing for hidradenitis suppurativa, why and how. J Am Acad Dermatol 2010; 63:481.e1.
- Finley EM, Ratz JL. Treatment of hidradenitis suppurativa with carbon dioxide laser excision and second-intention healing. J Am Acad Dermatol 1996; 34:465.
- Hazen PG, Hazen BP. Hidradenitis suppurativa: successful treatment using carbon dioxide laser excision and marsupialization. Dermatol Surg 2010; 36:208.
- Mikkelsen PR, Dufour DN, Zarchi K, Jemec GB. Recurrence rate and patient satisfaction of CO2 laser evaporation of lesions in patients with hidradenitis suppurativa: a retrospective study. Dermatol Surg 2015; 41:255.
- Ritz JP, Runkel N, Haier J, Buhr HJ. Extent of surgery and recurrence rate of hidradenitis suppurativa. Int J Colorectal Dis 1998; 13:164.
- Menderes A, Sunay O, Vayvada H, Yilmaz M. Surgical management of hidradenitis suppurativa. Int J Med Sci 2010; 7:240.
- Rubin RJ, Chinn BT. Perianal hidradenitis suppurativa. Surg Clin North Am 1994; 74:1317.
- Rompel R, Petres J. Long-term results of wide surgical excision in 106 patients with hidradenitis suppurativa. Dermatol Surg 2000; 26:638.
- Watson JD. Hidradenitis suppurativa--a clinical review. Br J Plast Surg 1985; 38:567.
- Nesmith RB, Merkel KL, Mast BA. Radical surgical resection combined with lymphadenectomy-directed antimicrobial therapy yielding cure of severe axillary hidradenitis. Ann Plast Surg 2013; 70:538.
- Ramasastry SS, Conklin WT, Granick MS, Futrell JW. Surgical management of massive perianal hidradenitis suppurativa. Ann Plast Surg 1985; 15:218.
- Hughes LE, Harrison BJ, Mudge M. Surgical management of hidradenitis-principles and results. In: Acne and related disorders, Marks R, Plewig G (Eds), Dunitz, London 1989. p.367.
- Maeda T, Kimura C, Murao N, Takahashi K. Promising long-term outcomes of the reused skin-graft technique for chronic gluteal hidradenitis suppurativa. J Plast Reconstr Aesthet Surg 2015; 68:1268.
- Kinoshita-Ise M, Nakamura Y, Kumagai Y, et al. Successful treatment of widespread chronic gluteal hidradenitis suppurativa with combination of recycled skin graft and negative-pressure wound therapy. J Dermatol 2016.
- Kuo HW, Ohara K. Surgical treatment of chronic gluteal hidradenitis suppurativa: reused skin graft technique. Dermatol Surg 2003; 29:173.
- Chen YE, Gerstle T, Verma K, et al. Management of hidradenitis suppurativa wounds with an internal vacuum-assisted closure device. Plast Reconstr Surg 2014; 133:370e.
- Lapins J, Emtestam L. Surgery. In: Hidradenitis suppurativa, 1st ed, Jemec GBE, Revuz J, Leyden J (Eds), Springer, Berlin 2006. p.160.
- Jemec GBE, Revuz J. Treatment. In: Hidradenitis Suppurativa, 1st ed, Jemec GBE, Revuz J, Leyden J (Eds), Springer, Berlin 2006. p.183.
- Parrado R, Cadena M, Vergara A, et al. The role of negative pressure wound therapy in the management of hidradenitis suppurativa: a case report and literature review. Int Wound J 2017; 14:35.
- GENERAL CONSIDERATIONS
- PERIOPERATIVE MEDICATION MANAGEMENT
- Preoperative treatment
- LOCAL PROCEDURES
- Punch debridement
- Unroofing (local or extensive)
- Role for I&D
- WIDE EXCISION AND RECONSTRUCTION
- Breasts and lower abdomen
- POSTOPERATIVE CARE AND FOLLOW-UP
- Negative pressure wound therapy
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS