Lasers and intense pulsed light (IPL) treatment are useful for the treatment of hidradenitis suppurativa (HS). Carbon dioxide lasers are used for cutting or vaporization of the affected area. It is a effective therapy for the management of severe and recalcitrant HS with persistent sinus tract and scarring, and can be performed under local anesthesia. HS has a follicular pathogenesis. Lasers and IPL targeting the hair have been found useful in treating HS by reducing the numbers of hairs in areas with HS. The methods have few side effects, but the studies are preliminary and need to be repeated.
Key points
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Lasers and intense pulsed light are useful in the treatment of hidradenitis suppurativa (HS).
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Carbon dioxide laser is used as a surgical instrument for cutting or vaporization of stationary HS elements.
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Hair removal by lasers and light devices destroys the hair follicles and thereby reduces the disease activity in the affected area.
Introduction: nature of the problem
The use of lasers and intense pulsed light (IPL) in the treatment of dermatologic conditions has increased over the past years. The carbon dioxide (CO 2 ) laser was the first used to treat hidradenitis suppurativa (HS) lesions. It is used as a surgical instrument for cutting or vaporization of the affected area with the advantage of a “blood-free” operation field and therefore removal with better control of subtle differences in the tissue. The better visualization provides the possibility of a macroscopic “Mohs-like” approach, in which only the minimum of tissue is removed.
More recently, other lasers and IPL targeting the hair have been tested and found useful. The methods aim at reducing the numbers of hairs in areas with HS. In particular, the Nd:YAG laser is a promising therapeutic option because of its deep tissue penetration, but alexandrite laser, diode laser, and IPL have also been used in a limited number of studies. The studies all report improvement of HS after treatment.
Introduction: nature of the problem
The use of lasers and intense pulsed light (IPL) in the treatment of dermatologic conditions has increased over the past years. The carbon dioxide (CO 2 ) laser was the first used to treat hidradenitis suppurativa (HS) lesions. It is used as a surgical instrument for cutting or vaporization of the affected area with the advantage of a “blood-free” operation field and therefore removal with better control of subtle differences in the tissue. The better visualization provides the possibility of a macroscopic “Mohs-like” approach, in which only the minimum of tissue is removed.
More recently, other lasers and IPL targeting the hair have been tested and found useful. The methods aim at reducing the numbers of hairs in areas with HS. In particular, the Nd:YAG laser is a promising therapeutic option because of its deep tissue penetration, but alexandrite laser, diode laser, and IPL have also been used in a limited number of studies. The studies all report improvement of HS after treatment.
Carbon dioxide laser
CO 2 laser vaporization surgery of HS was first introduced in 1987 by Sherman and Reid. Initially, HS of the vulva was treated and later the method was extended for use in other body areas. In the early 1990s, with the arrival of scanners for CO 2 lasers, a smoother, faster, and safer removal of the pathologic tissues could be performed.
Treatment Goal and Planned Outcome
All operative techniques to treat HS aim at radically removing all keratinocytes and their potential remnants in nodules, abscesses, and tunnels. This can be done through excision en bloc of the whole involved skin area or more selectively through vaporization of the pathologic tissue only ( Table 1 ).
| Patients (Anatomic Sites) | Method | Anesthesia | Healing | Healing Time | Follow-up (Range) | Cure Rate a | Reference |
|---|---|---|---|---|---|---|---|
| Laser excision | |||||||
| 61 (185) | 8–30 W | LA (99%) | SI | 8.8 wk | 1–19 y | 98.9% | Hazen & Hazen, 2010 |
| 9 (27) | 18–40 W | GA (42%) LA (58%) | PC | NA 2–4 wk b | 1 y | 89.9% | Madan et al, 2008 |
| 7 (13) | 40 W | LA | SI | 4–11 wk | 10–27 mo | 92% | Finley & Ratz, 1996 |
| Vaporization | |||||||
| 24 | 30 W, spot size 2 mm | LA | SI | 3–5 wk | 27 mo (15–47) | 92% | Lapins et al, 1994 |
| 34 | Scanner-assisted, 20–30 W, spot size 3–6 mm | LA | SI | 4–11 wk | 34.5 mo (7–87) | 88% | Lapins et al, 2002 |
| 6 | Narrow beam (1.6 mm), until depth 3–8 mm | NA | SI | 3–7 wk | (9–36 mo) | 100% | Dalrymple & Monaghan, 1987 |
| 1 | 10–15 W | GA | Skin graft | NA | 1 y | 100% | Natarajan et al, 2014 |
| 11 | NA | NA | SI | 2–8 wk | NA | 100% | Sherman & Reid, 1991 |
| 58 | Scanner assisted 20–35 W, spot size 4 mm | GA LA | SI | NA | 20.6 mo (1–47) | 71% | Mikkelsen et al, 2015 |
a Cure rate of operation site.
Carbon dioxide laser excision surgery (en bloc)
CO 2 laser can be used to excise smaller or larger skin areas en bloc with or without laser coagulation of remnants (marsupialization) in the deep tissues, with less bleeding and better visualization than in standard excisions. This can also be achieved by electrosurgery, which may be used in a similarly tissue-sparing stepwise procedure. This method is best suited for patients with stationary lesions (Hurley stages II-III). The reported results indicate a cure rate of 89.9% to 98.9% for specific lesions (see Table 1 ).
Carbon dioxide laser vaporization surgery (selective focal treatment)
Scanner-assisted CO 2 laser treatment aims at focal radical treatment through vaporization of all nodules, abscesses, and fistulas, leaving healthy tissues in between the pathologic lesions untouched. This method is best suited for patients with smaller stationary lesions.
Starting in the center of a lesion, the tissue is vaporized in layers in a stepwise manner. The procedure is guided continuously by macroscopic inspection of the visible pathologic tissues and the goal is to remove all diseased tissue and reach healthy tissues in all directions, that is, complete removal both laterally and in depth. In this way, the technique can be tissue sparing and at the same time radical, much in analogy to the principles of Mohs surgery. Normal skin in between the HS lesions is left untouched and the wounds are left to healing by secondary intention. The reported cure rates are between 71% and 100% (see Table 1 ).
Preoperative Planning and Preparation
The diseased skin is examined macroscopically for scarring, tissue distortion, and discoloration; dry or suppurating sinuses; macropseudocomedones; and other superficial signs. Symptomatic lesions are selected for the treatment (ie, those with discharge, inflammation, infiltration, or suspected abscesses). Areas that had been asymptomatic for more than 2 years but show signs of previous activity (eg, scars with postinflammatory hyperpigmentation, and sometimes with dry pseudocomedones) but no current inflammation are usually not treated. The examination is completed by palpating the defects for bulky indurations and small, firm subcutaneous nodules or fluctuating purulent tissue. The affected areas are delineated with ink. Excised tissue en bloc or a preoperative biopsy for histopathology is recommended to exclude squamous cell carcinoma if clinically suspected.
Anesthesia
The choice of local or general anesthesia depends on the size and numbers of areas to be excised. Several approaches are outlined by Horvath and colleagues.
Operative Techniques
In general, 2 different CO 2 laser methods are used: vaporization and excision (combined with marsupialization).
Vaporization technique
A scanner-assisted CO 2 laser is used. This is a laser with a focusing handpiece attached to the miniature optomechanical flash scanner delivery system that generates a focal spot, which moves rapidly and homogeneously in spiral scans and covers a round area on tissue at the focal plane. The area selected is gradually ablated by the laser beam when it passes over the tissue repeatedly. The aim of this procedure is to reduce thermal damage to adjacent tissue. Devitalized tissue is removed gently by cleansing the surface with swabs soaked in 0.9% sodium chloride solution. The depth of the vaporization is controlled by the selection of power, focal length, scanner-controlled spot size, and the movements of the handheld scanner. Often, 20 to 50 W, a spot size of 3 to 6 mm, and a focal length setting of 12.5 or 18 cm can be used. The vaporization procedure is repeated in downward and outward directions until fresh yellow adipose tissue is exposed in the deep, relatively thin, and anatomically normal skin margins laterally, with no remaining dense or discolored tissue. Usually, the vaporization reached the deep subcutaneous fat or fascia. In the axillary and inguinal regions, major vessels and the nerve plexus must be protected, but this depth is seldom reached in Hurley stage II lesions. The smaller blood vessels are coagulated by the laser, but bleeding from vessels larger than 0.5 to 1 mm in diameter is usually better addressed by electrocoagulation or ligation. The use of scanner-assisted CO 2 laser surgery on a case of axillary hidradenitis suppurativa is shown in Fig. 1 .
Related posts:
Prevalence, Risk Factors, and Comorbidities of Hidradenitis Suppurativa
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The Handicap of Hidradenitis Suppurativa
Endocrinologic Aspects of Hidradenitis Suppurativa
Inflammatory Mechanisms in Hidradenitis Suppurativa
Randomized Controlled Trials for the Treatment of Hidradenitis Suppurativa
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