Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease that has a social and psychosocial impact on patients with skin of color.1 It is characterized by recurrent abscesses, draining sinus tracts, and scarring in the intertriginous skin folds. The lesions are difficult to treat and present with considerable frustration for both patients and physicians. Although current treatment ladders can delay procedures and surgical intervention,1 some believe that surgery should be introduced earlier in HS management.2 In this article, we review current procedures for the management of HS, including cryoinsufflation, incision and drainage, deroofing, skin tissue–saving excision with electrosurgical peeling, and wide surgical excision, along with various closure techniques.
First described in 2014, cryoinsufflation is a novel method for treating sinus tracts.3 Lesions initially are identified on physical examination. Prior to the procedure, local anesthesia is administered to the lesion.3 A 21-gauge needle is mounted onto a cryosurgical unit and inserted into the opening of the sinus tract. Liquid nitrogen is sprayed into the tract for 5 seconds, followed by a 3-second pause; the process is repeated 3 times. Patients return for treatment sessions monthly until the tract is obliterated. This procedure was first performed on 2 patients with satisfactory results.3
Since the initial report, the investigators made 2 changes to refine the procedure.4 First, systemic antibiotics should be prescribed 2 months prior to the procedure to clear the sinus tracts of infection. Furthermore, a 21-gauge, olive-tipped cannula is recommended in lieu of a 21-gauge needle to mitigate the risk of adverse events such as air embolism.4
Incision and Drainage
Incision and drainage provides rapid pain relief for tense fluctuant abscesses, but recurrence is common and the procedure costs are high.5 For drainage, wide circumferential local anesthesia is administered followed by incision.6 Pus is eliminated using digital pressure or saline rinses.2 Following the elimination of pus, the wound may need gauze packing or placement of a wick for a few days.6 The general belief is that incision and drainage should be used, if necessary, to rapidly relieve the patient’s pain; however, other surgical options should be considered if the patient has had multiple incision and drainage procedures.7 Currently there are no randomized controlled trials (RCTs) on incision and drainage procedures in HS abscesses.
In 1959, Mullins et al8 first described the deroofing procedure, which was refined to preserve the floor of the sinus tract in the 1980s.9,10 Culp10 and Brown et al9 theorized that preservation of the exposed floor of the sinus tract allowed for the epithelial cells from sweat glands and hair follicle remnants to rapidly reepithelialize the wound. In 2010, van der Zee et al11 performed a prospective study of 88 deroofed lesions in which the investigators removed keratinous debris and epithelial remnants of the floor due to concern for recurrence in this area if the tissues remained. Only 17% (15/88) of the lesions recurred at a median follow-up of 34 months.11
In Hurley stage I or II HS, deroofing remains the primary procedure for persistent nodules and sinus tracts.2 The lesion is identified on physical examination and local anesthesia is administered, first to the area surrounding the lesion, then to the lesion itself.11 A blunt probe is used to identify openings and search for connecting fistulas. After defining the sinus tract, the roof and wings created by the incision are removed.11,12 The material on the floor of the tract is scraped away, and the wound is left to heal by secondary intention.11 In general, deroofed lesions heal with cosmetically acceptable scars. We have used this procedure in skin of color patients with good results and no difficulties with healing. Controlled trials with long-term follow-up are lacking in this population.
Skin Tissue–Saving Excision With Electrosurgical Peeling
Skin tissue–saving excision with electrosurgical peeling was first introduced in 2015.13 Blok et al14 described the procedure as a promising alternative to wide surgical excision for Hurley stage II or III HS. The procedure saves healthy tissue while completely removing lesional tissue, leading to rapid wound healing, excellent cosmesis, and a low risk of contractures2,14; however, recurrence rates are higher than those seen in wide surgical excision.15 There are no known RCTs with long-term follow-up for HS patients treated with skin tissue–saving excision with electrosurgical peeling.
The procedure typically is performed under general anesthesia.14 First, the sinus tract is palpated on physical examination and probed to delineate the extent of the tract. Next, the roof of the tract is incised electrosurgically with a wire loop tip coupled to an electrosurgical generator.14 Consecutive tangential excisions are made until the floor of the sinus tract is reached. The process of incising sinus tracts followed by tangential peeling off of tissue continues until the entire area is clear of lesional and fibrotic tissue. The wound margins are probed for the presence and subsequent removal of residual sinus tracts. Lastly, the electrosurgical generator is used to achieve hemostasis, steroids are injected to prevent the formation of hypergranulation tissue, and the wound is left to heal by secondary intention.14 Following intervention, recurrence rates appear to be similar to wide surgical excision.13,14