Case 18: Surgical management of hidradenitis suppurativa

With limited data available on randomised clinical trials on the treatment of hidradenitis suppurativa, a multidisciplinary approach including mainly dermatologist and plastic surgeon is key to prompt optimal disease control. A personalised treatment plan is usually constructed by dermatologist. An assessment by a plastic surgeon is proposed for selected patients with Hurley stage 1 and all patients with Hurley stages 2 and 3. The most commonly proposed surgical approach consists of wide excision of lesions and reconstruction with dermoepidermal grafts when primary closure is impossible. For obese patients (BMI ≥ 30 mg/m2), a consultation with a physician who specializes in nutrition is proposed. For patients with class 2 obesity (BMI ≥ 35 mg/m2), a bariatric intervention with a bariatric surgeon can be discussed. Female patients with clinical signs of hyperandrogenism or hormone serum abnormalities are referred to an endocrinologist. (3) Patients are advised to control their weight and refrain from smoking. The early stages can be managed with topical or systemic antibiotics or immunosupresive treatment, but the advanced stages mostly require surgical intervention. (4) Stage I is managed with topical antibiotic therapy, e.g. Clindamycin 10mg/ml twice a day for three months has been reported to reduce the number of abscesses, nodules and pustules. When topical treatment is insufficient, oral antibiotics are commonly used or a combination of topical and oral antibiotics. (5) Anti-androgen drugs are sometimes used in women, though the patient did not undergo anti-androgen treatment. Systemic immunosuppressives are recommended to patients with high stage disease with abscesses, extensive scaring and cysts. Adalimumab, an anti-TNFα monoclonal antibody sold under the brand name Humira has been used with good results. (6) Surgery is used in patients with stage III or stage II in those who have extensive scarring and are non-responsive to treatment mentioned above. Severe forms of hidradenitis suppurativa can often lead to severely mutilating procedures. Incision and drainage of acute lesions provide a rapid relief of the symptoms, but recurrence rates are close to 100%. (6) In patients with less extensive disease, local excision of sinus tracts, cysts and abscesses is usually sufficient and can be left open to heal by secondary intention. The patient was treated by antibiotic therapy for 2 years after the diagnosis with unsatisfactory response, so the decision to start biological therapy was made. She has been undergoing treatment by adalimumab inj. s.c. once in 2 weeks for about 8 months and she was recommended surgical treatment. In this case, more extensive procedure was required involving wide excision of skin in the affected areas.