Surgical excision and reconstruction of stage III Hidradenitis Suppurativa of the male and female genitalia: A Case Series

Introduction: Hidradenitis Suppurativa is an inflammatory condition of pilosebaceous units characterized by recurrent, painful nodules, purulent abscesses, and chronic sinus tracts. It occurs in intertriginous areas, which are difficult to heal due to moist environment, high friction, bodily functions, and chronic contamination. In addition to the pain and psychosocial distress, hidradenitis can lead to complications including lymphedema, chronic, inflammatory disease processes, and anemia. The genital area is prone to severe lymphedema due to vascularity, expansile skin, and potential for fibrotic outflow obstruction at the groin crease. Treatment for Hurley stages I and II hidradenitis includes antibiotics, corticosteroids, biologic drugs, and bedside incision and drainage. Hurley stage III hidradenitis often requires wide, surgical excision and debridement and complex wound healing. This case series describes the outcomes of surgical excision and reconstruction of severe genital hidradenitis, in both males and females.Methods:Three patients with Hurley Stage III hidradenitis presented with tunneled, fibrotic wounds of the genitalia, perineum, and thighs. Wide excision was performed in conjunction with the respective genital surgeons, gynecology-oncology or urology. These teams resected the genitalia, preserving critical structures, including the testicles, spermatic cords, clitoris and vagina. Next, varying reconstructive techniques were utilized, including complex closures and local perineal advancement flaps. Iodine-impregnated wicks were placed to allow drainage. Morselized ovine forestomach matrix (OFM) was applied to the incisions to facilitate wound healing. Results:All three patients had massive resected tissue weighing between 1000g and 6000g. All had minor wound healing complications, which resolved with local wound care, in-clinic debridement, and frequent follow-up. One patient underwent an elective debridement in the operating room with successful reclosure.Discussion: These cases demonstrate the efficacy and importance of surgical intervention for severe genital hidradenitis to allow patients to regain mobility, normal anatomic function, and quality of life. The strong potential for wound complications in the genital area, effects of chronic inflammation, and psychosocial distress associated with hidradenitis make these cases highly complex and multifaceted, requiring both medical and surgical management. Utilization of a multidisciplinary team of surgeons to preserve and reconstruct genital structures in combination with diligent post-operative wound care can improve patient outcomes.References:Ballard K, Shuman VL. Hidradenitis Suppurativa. 2024 May 6. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan. PMID: 30521288. Goldburg SR, Strober BE, Payette MJ. Hidradenitis suppurativa: Epidemiology, clinical presentation, and pathogenesis. Journal of the American Academy of Dermatology. 2020 May;82(5):1045-1058. doi: 10.1016/j.jaad.2019.08.090. Epub 2019 Oct 9. PMID: 31604104. Jenkins T, Isaac J, Edwards A, Okoye GA. Hidradenitis Suppurativa. Dermatologic Clinics. 2023 Jul;41(3):471-479. doi: 10.1016/j.det.2023.02.001. Epub 2023 Apr 15. PMID: 37236715. Ludmann, P. Hidradenitis Suppurativa: Diagnosis and treatment. American Academy of Dermatology Association. 2022 May 3. https://www.aad.org/public/diseases/a-z/hidradenitis-suppurativa-treatment.