Highlights from

WCD 2019

World Congress of Dermatology

Milan 10-15 June 2019

Surgeries in hidradenitis suppurativa

There are many efficacious surgical options for hidradenitis suppurativa (HS), mostly needing long wound care and a committed patient.

Mostly, stage 3 HS is when surgery is discussed, but it can be also an option in solitary lesions [1]. “Surgery should definitely be considered in diffuse or nearly diffuse areas, unresponsive lesions with failed topical or systemic therapy, and in the case of considerable scarring,” explained Dr Stanislav Tolkachjov (Mohs Surgery, USA). Possible good choices for HS are deroofing/unroofing, skin tissue-saving excision with electrosurgical peeling (STEEP), and wide surgical excision (WLE) [1]. Before deciding on surgery, the patient needs to understand that the disease can recur and has to be willing to go through long-term wound care and potential multiple procedures. In extensive gluteal disease, a diverting ostomy might facilitate difficult wound care.

Deroofing is a surgical option that can be done by the dermatologist. It can be used in stage 1 and 2 or as adjunct procedure in stage 3. After local and sometimes tumescent anaesthesia, a blunt probe is inserted to follow the sinus tract and the roof is cut and coagulated electrosurgically. Thereafter, the inflammatory material needs to be removed by scraping the floor with dry gauze or curette [1,2]. Especially in deroofing, CO2 laser vaporisation is a good surgical method for small but persisting lesions [3].

STEEP is an intermediate option between deroofing and WLE, removing more fibrous tissue than the first, but maximally sparing the subcutaneous fat [1,4]. STEEP and WLE are done under general anaesthesia. In comparison to WLE, STEEP is likely followed by fewer contractions. In WLE, the surgeon strives to remove the clinically diseased or fibrous tissue until normal fat is visualised. Primary wound closure is mostly avoided. Vacuum-assisted closure, negative pressure wound treatment with instillation, and grafts can be an option [1,5,6]. “About half of the time inflammatory nodules pop up right around the site of the operative field, but that doesn’t mean that the patients aren’t doing better in terms of their symptoms,” Dr Tolkachjov commented. Procedures under local anaesthesia recur more often compared with the ones under general anaesthesia (40.6% vs 28.6%) [7]. Most patients showed relevant long-term benefit from WLE and no sinus tracts, fistulas, nor HS-related scar formation [1]. “Try putting yourself in the place of the patient with severe HS and you forget all about the difficulty of treating HS,” Dr Tolkachjov invited his fellow physicians in conclusion.

  1. Tolkachjov S. 24th World Congress of Dermatology, 10-15 June 2019, Milan, Italy.
  2. Van der Zee HH, et al. J Am Acad Dermatol 2010;63:475-80.
  3. Van der Zee HH. 24th World Congress of Dermatology, 10-15 June 2019, Milan, Italy.
  4. Blok JL, et al. J Eur Acad Dermatol Venereol. 2015;29:379-82.
  5. Ge S, et al. Cureus 2018;10:e3319.
  6. Yamashita Y, et al. Dermatol Surg 2014;40:110-5.
  7. Walter AC, et al. Dermatol Surg. 2018;44:1323-1331.

Top image: @ iStockPhoto: AzmanL

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