Introduction
In the last few decades, surgical interventions for hidradenitis suppurativa (HS) have expanded well beyond traditional excisional approaches with the popularization of deroofing, the use of electrosurgical and laser-based excisions, and combined approaches that take both medical and surgical management into account. Equally important has been the motivation to move some procedures out of operating rooms with general anesthesia and into a clinic-based approach that makes surgical treatment more accessible and safer for many patients. With this movement comes important considerations regarding how to approach procedures in the outpatient setting. This chapter will explore frequently used clinic-based procedures and describe the appropriate way to plan for, perform, and postoperatively care for patients that choose these procedures as part of their care.
General Approach to Procedures
HS is a follicular disorder characterized by follicular rupture and chronic inflammation with terrible consequences in predictable anatomic areas in susceptible patients. The body’s disordered attempt to re-epithelialize the exposed surfaces under the skin results in the formation of sinus tracts filled with a semi-solid substance, a disease-specific bacterial microbiome (heavy in anaerobes and organized in biofilms), and related inflammatory elements collectively designated by Danby as the “invasive proliferative gelatinous mass” or IPGM of HS. This trapped mass of sinus tracts and the IPGM are responsible for the enduring or episodic inflammatory symptoms in patients with the disease: pain, suppuration and purulent drainage, odors, scar-formation, overall debility, and sexual dysfunction. Late sequela of the disease may include lymphedema and squamous cell carcinoma. A discussion about complications from HS disease can be found in Chapter 9 .
The optimal treatment of HS includes three broad categories of intervention: (1) prevention of new lesion formation, (2) palliation of suffering from existing lesions, and (3) the extirpation/destruction of established lesions which, when left alone, continue to drive inflammation and suffering. Resolution of HS is achieved when there is complete prevention of new lesions and all existing lesions have either been extirpated, “burnt out,” or are otherwise eliminated. Medical strategies, including lifestyle modifications and topical and systemic agents, have considerable value in minimizing new lesions and disease progression, but physical remodeling of tissues and some degree of inflammation typically persist where sinuses have formed. Symptoms in these areas often last for years or even indefinitely, so surgical interventions that remove or resolve the tunneling are critical for relieving long-term symptoms.
Office procedures play a central role in all three treatment categories and are the focus of this chapter ( Table 22.1 ). There are many choices, but we stress the importance of the deroofing technique as the central and most essential office-based technique in the care of these patients . Deroofing is safe and effective, it can be done with simple tools readily available in any office that regularly performs other procedures like excisions, and involves application of skills that essentially all dermatologists and other surgically trained physicians acquire in the course of their residency training. Deroofing is also an inexpensive procedure.
| Office Procedures Intended to Prevent New Hidradenitis Suppurativa Lesion Formation | Office Procedures Intended to Mitigate Inflammation and Pain in Established Lesions | Office Procedures Intended to Resolve Chronic or Recurrent Lesions |
|---|---|---|
| Chemical Peels Radiation Neurotoxins Laser and light epilation (see Chapter 25 ) Photodynamic therapy (see Chapter 25 ) | Intralesional Triamcinolone Incision and Drainage Radiation Photodynamic therapy (see Chapter 25 ) | Deroofing Local Excision (see Chapter 23 and 24 ) Laser Destruction (see Chapter 25 and 26 ) Cryoinsufflation (see Chapter 26 ) |
In considering the appropriateness of office-based procedural interventions (indeed, all interventions), clinicians must proceed from history and physical examination and categorization of the extent and complexity of individual foci of the disease. The most useful classification schema for this purpose was defined by Hurley and is widely known as Hurley Staging :
Hurley Stage I: Abscess formation, single or multiple, without sinus tracts and cicatrization
Hurley Stage II: Recurrent abscesses with tract formation and cicatrization; single or multiple widely separated lesions
Hurley Stage III: Diffuse or near diffuse involvement, or multiple interconnected tracts and abscesses across entire area
In this chapter, we consider several treatments which have varying efficacy and make more sense when applied to the correct clinical stage of a given focus of the disease and for the correct purpose ( Table 22.2 ). Educating the patient on the nature of the disease and the purpose of any given procedure is vital to the success of these endeavors. For example, laser epilation is intended to destroy hair follicles in HS-prone areas in a predisposed patient; each destroyed follicle is one less potential site of inflammation and follicular rupture. However, laser epilation may have no effect on longstanding lesions. Intralesional injections of triamcinolone or incision and drainage of individual lesions may have valuable palliative effect on treated lesions for a few to several weeks. However, if the patient believes that these treatments were intended to “cure” the lesion, then those procedures may be considered failures after symptoms return. The deroofing technique and its variants can reliably resolve specific sinuses but have no specific impact on preventing new disease. Thus, office procedures must fit into a well-conceived program of multi-modal medical and surgical care. Starting with patient education, small procedural interventions and building trust in the patient-physician relationship is an optimal way to care for the patient with HS.
| Hurley Stage | Intralesional Triamcinolone | Incision and Drainage | Deroofing | Local Excision | Neurotoxins | Chemical Peels | Radiation |
|---|---|---|---|---|---|---|---|
| Stage I | ++ | ++ | + | – | + | ++ | – |
| Stage II | ++ | ++ | +++ | ++ | + | + | + |
| Stage III | + | ++ | +++ a | – | – | – | + |
a For practical reasons, i.e., limitations of time and local anesthetic toxicity limits, deroofing is sometimes performed in a staged manner or limited to one body site for each surgical episode in Hurley Stage III disease. These patients may prefer procedures performed with general anesthesia in an operating room, but based on patient preference, in-office deroofing or excisions have value as time permits and may be achieved by use of more dilute concentrations of anesthetics or with tumescent anesthesia for extensive areas.
Preoperative Anesthesia/Anxiolytics
HS is painful, and its lesions are tender. In nearly all cases, office procedures are also painful. Compassionate procedural care of non-sedated patients with HS requires careful consideration of acute intra-procedural pain and anticipatory anxiety. Failure to address these may convince patients that procedures that would otherwise help them are intolerable, thereby unnecessarily narrowing the therapeutic armamentarium. Certain patients may benefit from a pre-procedure oral anxiolytic with a single dose of a benzodiazepine, such as 1 to 2 mg lorazepam or 10 mg of diazepam given 30 to 60 minutes prior to the procedure. Pretreating areas with topical anesthetics, such as commercially available eutectic mixture of local anesthetics (e.g., 2.5% lidocaine and 2.5% prilocaine applied for at least 1 hour) under occlusion or compounded high-concentration anesthetic creams (e.g., lidocaine 23% and tetracaine 7%), may facilitate the tolerability of definitive local anesthesia (via injection) for deroofing or before injection of intralesional triamcinolone, neurotoxins, or laser treatments. Skin cooling with 10 to 15 seconds of ice pack application or similar methods can also help ease injection pain.
Direct injection of local anesthetics is the principal approach to eliminating procedural pain and limiting procedural blood loss during office procedures like deroofing. The commonly used amine is lidocaine with epinephrine. A rule of thumb is that 0.5 to 1 mL of lidocaine 1% with epinephrine 1:100,000 per square centimeter of planned treatment area will suffice, modified for lesional thickness as indicated. Warming anesthetics, high gauge (i.e., small) needles, slow injection, buffering with 1:10 dilution of sodium bicarbonate and topical pre-treatments may lessen the pain associated with local anesthesia. The approach of the authors is to start with a ½-inch 30-gauge needle to create a small area for anesthesia through which a 1.5 inch 25- or 27-gauge needle can be introduced. Using a fanning technique, large areas can be anesthetized with relatively few individual injections sites, and this also allows for deeper anesthesia when needed.
The proceduralist can begin by injecting anesthetic in a ring at the periphery of the lesion. Then, a small amount of anesthetic can be introduced directly into sinus tracts with the twin benefits of dilating those tracts to facilitate the probing step of deroofing and distributing anesthetic throughout the lesion. Finally, the rest of the lesion is injected. Starting in a superficial subcutaneous plane is often well-tolerated and makes the subsequent anesthesia of the dermis less painful. Awareness of the systemic toxicity from lidocaine overload (limit to 7 mg/kg when using lidocaine with epinephrine) is essential given the size of lesions treated in office settings. Indeed, lidocaine toxicity limits are one of the key parameters limiting the size of office-setting deroofing procedures. Diluting the lidocaine component to 0.5% or 0.25% can greatly expand the area that can be safely treated. Performing serial deroofing procedures in smaller stages or using tumescent anesthesia are additional strategies for treating larger lesions.
Intralesional Triamcinolone
Intralesional triamcinolone has been used frequently in the management of HS for many years. Despite this, little data exists that supports efficacy and provides guidance on the optimal concentration, volume, and clinical context for its use. An uncontrolled retrospective study using average volumes of 0.75 mL of triamcinolone 10 mg/kg demonstrated improved pain and physician-reported outcomes over a 7-day period, but lacked a control group for comparison. Another prospective study using ultrasound to identify and follow small (mean 5 to 17 mm) fistulous tracts found that nearly half resolved at 90 days after treatment with a mean of 0.5 mL of triamcinolone 10 mg/mL. While promising, this study similarly lacks a control group and there is uncertainty regarding the typical natural history of relatively small fistulous tracts as determined by ultrasound.
A recent randomized controlled trial evaluated 0.1 mL of intralesional triamcinolone 10 mg/mL, 40 mg/mL versus non-bacteriostatic normal saline for the treatment of isolated nodules or abscesses less than 2 cm in size. Fifty-eight lesions had outcome data. Similar improvements in pain visual analog scale change, days to lesions resolution as determined by patients, and patient satisfaction were found across all three groups throughout a 14-day follow-up period. While the lack of improvement compared to the normal saline control is discouraging, the overall volume of triamcinolone used in this study was lower than in the previous uncontrolled studies. Of great interest is the finding that even patients receiving normal saline injections consistently reported benefit. While a placebo effect is possible, it is also possible that puncturing a lesion and instilling an external solution alone is helpful.
While the current data on the efficacy of triamcinolone is mixed, many patients report benefit and request treatment in clinical practice. Given the low overall risk, it is reasonable to offer treatment and discuss the available evidence regarding efficacy. In some patients that are hesitant to undergo injections due to pain, the limitations of this treatment and alternatives should be considered. For patients with widespread disease, it is also important to consider systemic absorption and potential side effects, which, while uncommon, do sometimes occur with repeated doses of 60 mg or more. Doses in the 30 to 60 mg range have been found to induce slight changes in the hypothalamic pituitary axis but generally do not result in symptomatic effects. Doses under 20 mg generally have negligible systemic effect. Future studies evaluating a range of doses and concentrations with appropriate control groups are needed to determine the optimal way to utilize intralesional steroids for acute HS flares.
From a practical standpoint, use of intralesional triamcinolone is straightforward. Use of skin cooling and topical anesthetics can reduce injection pain but are not frequently required. The skin is cleaned with alcohol, taking care to avoid ulcerated skin in which this would be more painful. Quick introduction of the needle, aiming for the dermal component of a nodule or into an inflamed sinus is ideal, followed by slow injection. In darker-skinned patients, care should be taken to minimize superficial infiltration that may lead to hypopigmentation. In some cases, introducing the needle directly through the opening of a sinus may be less painful than the surrounding skin. A concentration of 10 mg/mL should be used when treating many lesions, while fewer may be treated with 40 mg/mL to help minimize the overall dose administered. The dose of 0.1 to 1 mL may be administered in one or multiple injection sites depending on lesion size, typically with 0.1 to 0.2 mL per square centimeter of affected tissue. Aftercare is typically not required.
Incision and Drainage
The conflation of HS with simple bacterial abscesses is perhaps the single biggest cause of delayed diagnosis (averaging 7 to 10 years), mistreatment, and physician contribution to patient suffering in the care of this disease. The most frequently misapplied procedure in this context is incision and drainage, which has great value in the cure of bacterial abscess or pain relief for an acute HS abscess, but limited value for definitively resolving chronic or recurrent lesions. In bacterial abscesses, incision and drainage eliminates the motherlode of etiopathogenic material—the stew of bacteria and pus. However, in HS, the ongoing driver of inflammatory symptoms—the trapped epithelial elements and the IPGM—remain in part or in whole after incision and drainage attempts. For lesions that are already persistently draining, incision and drainage typically serves little purpose. Deroofing is often indicated instead.
Appropriate Use of Incision and Drainage
When does it make sense to incise and drain an HS lesion? Danby describes the specific indication that justifies it as follows. “A tense abscess that is too painful to bear should be incised after wide circumferential local anesthesia… The actively growing IPGM is not eliminated. An alternative surgical approach is indicated.” In the case of small, early abscesses, intralesional triamcinolone may achieve the same effect both through the introduction of the corticosteroid and puncturing, but abscesses larger than 2 cm may ultimately require surgical or spontaneous drainage before improving. When incision and drainage is appropriately chosen, a technique familiar to the proceduralist for abscess drainage will generally suffice. However, packing is generally not needed as it often results in increased morbidity and has not been shown to improve outcomes in comparative studies.
In the experience of the authors, anesthesia can typically be limited to a focal area of the abscess that looks and feels most superficial. A 6-mm punch tool can be used to incise the lesion and can be used in telescoping fashion if needed to access the abscess cavity ( 
). This typically allows for rapid drainage without the need for intense pressure or pain once anesthesia is achieved for the incision. Care should be taken to cover the punch tool with gauze as pus may be rapidly propelled through the hub of the instrument on initial incision. The punch site can be covered with a simple bandage and left to heal by secondary intention, allowing the area to continue to drain for a few days if needed.
Deroofing
Deroofing (alternatively called unroofing or sinus tract exteriorization) is a simple technique, first described by Mullins et al. Table 22.3 and Figs. 22.1 and 22.2 summarize a practical approach to the procedure, and video is available online ( 
). Most typically, a sinus is marked and completely anesthetized. A blunt probe is gently passed into a sinus tract until resistance is encountered. The tract’s roof is cut open over the probe using sharp scissors, a scalpel, cutting electrical current, or ablative laser. The roof flaps are reflected and trimmed off at the hinge. Any newly exposed sinus tracts are probed and likewise treated. The exposed “floors” are optionally treated with sharp curettage and/or by raking them with coarse gauze applied with downward pressure to increase frictional forces; a maneuver termed “grattage.” The sum effect of this is to eliminate the gelatinous content of the sinus tract—the IPGM—without further tissue disruption. Hemostasis is achieved via ordinary methods and the wound is dressed and allowed to heal by secondary intent. Painful suppurating scarred lesions are replaced with quiescent soft scars, often much smaller than the area deroofed. Because hidradenitis is confined to the dermis and subcutis, the discipline of treating only probed tracts prevents surgical damage to deep structures like the brachial plexus in the axilla, and reduces risk of blind excisions. Hurley Stage I lesions, essentially furuncle-like abscesses occurring within a single folliculo-pilosebaceous unit and without sinus tract formation, can be treated with a modified version of deroofing known as “mini-unroofing.” Instead of probing and cutting into the roof of a sinus tract, a punch biopsy tool (between 5 and 8 mm in diameter) is used to open the cystic space. Table 22.3 provides a stepwise guide to the deroofing procedure and common variants. Hurley Stage III lesions may also be treated using deroofing and are often aided by some modifications: moving care to an operating room and using general anesthesia, using tumescent or more dilute anesthesia in the clinic setting, or by executing serial small deroofings in which each episode of care is limited to a portion of a lesion. Lesions 20 to 40 cm 2 are relatively straightforward and quick to treat, though areas over 100 cm 2 can be treated if the situation requires immediate attention, the patient prefers an outpatient setting, and if the practitioner’s time permits. In particular, patients with comorbidities that restrict access to general anesthesia may find the outpatient setting as their only avenue for surgical treatment.
| Standard Approach | Alternatives and Comments | |
|---|---|---|
| Supplies |
| See individual steps for alternative supplies |
| Patient Selection | Hurley Stage II and III patients, in most typical locations whether inflamed or not | Pilonidal cyst/sinus is a distinct entity and requires other techniques |
| Marking and Skin Preparation |
| Betadine or chlorhexidine may be used to clean the surgical area |
| Anesthesia |
| Pre-treat with topical anesthetic (e.g., lidocaine 2.5% and prilocaine 2.5%)
|
| Probing and Opening the Roof |
|
|
| “Excising at Hinge” |
| Trimmings can be sent to a pathologist for histologic confirmation. They should be sent if verrucous or nodular change is apparent to rule out a complicating squamous cell carcinoma. |
| Final Probing |
| |
| Treating the “Floor” |
| Areas where gelatinous material does not easily come free at an edge may indicate disease extension and should be carefully explored. |
| Hemostasis (3 P’s) |
| Ferric chloride or ferric subsulfate (Monsel’s solution) may be used instead of aluminum chloride for broad area hemostasis. |
| Repair | None (secondary intent) | If repair is desired, a full thickness excision is generally first performed around and deep in to the unroofed area to avoid trapping epithelialized elements deep to the repair. |
| Dressing |
| Xeroform or other petrolatum-impregnated gauze is an alternative |
| Wound Care and Analgesia |
| Patients with HS are usually wound care experts by the time they have their first deroofing |
| Follow-up |
|
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