Laser and Light Treatments for Hidradenitis Suppurativa

Abbreviations:

hidradenitis suppurativa

(HS)

carbon dioxide

(CO ₂ )

neodymium-doped yttrium aluminum garnet

(Nd:YAG)

Hidradenitis Suppurativa Clinical Response

(HiSCR)

Dermatology Life Quality Index

(DLQI)

photodynamic therapy

(PDT)

methyl aminolevulinate

(MAL)

5-aminolevulinic acid

(ALA)

methylene blue

(MB)

Introduction

In additional to traditional topical, medical, and surgical modalities, hidradenitis suppurativa (HS) can also be managed with laser and light-based treatments. These methods have the advantage of targeting affected areas with little to no systemic side effects. They can be used as monotherapy or combined with other treatments. These work by selective photothermolysis to target specific components of the skin and work via several mechanisms, including: debulking lesions, stimulating wound healing, improving scarring, decreasing inflammation, destroying hair follicles, targeting sebaceous glands, and killing bacteria (Fig. 25.1 ). Energy-based treatments are important options in the HS management ladder with different lasers recommended for various stages of severity ( Table 25.1 ). They are often used in conjunction with medical, surgical, and lifestyle modifications as part of comprehensive care for HS patients.

Table 25.1

Summary of Laser and Light-based Treatment Modalities

Treatment Modality	Level of Evidence	Mechanism of Action	Patient Selection	Pre- and Post- Procedure Care	Complications, Barriers, and Limitations
Ablative CO ₂	C	Tissue debulking or destruction	Patients with Hurley stage II or III disease with sinus tracts	Intralesional anesthesia pre-procedure, wound is typically left to heal via secondary intention-wound care needed until healing occurs	Patient discomfort, wound care necessary, risk of infection, nerve damage, and recurrence
Fractionated CO ₂	C	Improve scarring and stimulate wound healing	Patients with contracture from scarring	Petroleum jelly to the area post-procedure	Patient discomfort
Nd:YAG	B	Follicular destruction	All Fitzpatrick skin phototypes and all Hurley stages	None	• Patient discomfort • Requires more than one treatment
Alexandrite	C	Follicular destruction	All Hurley stages	None	• Patient discomfort • Requires more than one treatment
Diode	C	Follicular destruction	All Hurley stages	None	• Patient discomfort • Requires more than one treatment
Topical PDT	C	Tissue debulking or destruction and kill bacteria	Patients with superficial lesions	Incubation period of photosensitizer	• Patient discomfort • Requires more than one treatment
Intralesional PDT	C	Tissue debulking or destruction and kill bacteria	Patients with deep sinus tracts	Incubation period of photosensitizer	Patient discomfort, risk of infection
Nonablative Radiofrequency	C	Decrease sebaceous gland activity	All Hurley stages	None	Patient discomfort
Ablative Radiofrequency	C	Tissue debulking or destruction	Patients with deep sinus tracts	Intralesional anesthesia pre-procedure	Patient discomfort, risk of infection and burn
IPL	C	Follicular destruction and decrease inflammation	All Hurley stages	None	Patient discomfort
External Beam Radiation	C	Tissue destruction	Patients who have failed other treatments	None	Patient discomfort, risk of secondary malignancy

CO ₂, Carbon dioxide; IPL , intense pulsed light; Nd:YAG , neodymium-doped yttrium aluminum garnet laser; PDT , photodynamic therapy.

Carbon Dioxide Laser

The carbon dioxide (CO ₂ ) laser (10,600 nm) is used to treat active HS areas as well as for scarring secondary to HS itself or previous HS surgery. Use of CO ₂ to vaporize sinus tracts was first described in 1987 by Dalrymple and Monighan, and methods for CO ₂ laser excision have evolved from there.

Ablative

The CO ₂ laser can be used in the ablative setting to selectively excise HS affected areas while sparing unaffected tissue. It is recommended for patients with Hurley stage II and III HS who have fibrotic sinus tracts. This laser can be used on patients under local anesthesia (with or without tumescent anesthesia) in an outpatient office setting. This results in a decreased risk compared to traditional wide local excision under general anesthesia. Treatment settings include a fluence of 55 W with a 0.2 to 1 mm spot size. The hemostatic properties of the laser allow for excellent visualization of the operative field and accurate assessment of the excised area for residual sinus tracts. The resultant wound is typically left to heal via secondary intention ( Fig. 25.2 ). Thus, appropriate wound care is needed until healing occurs.