Hidradenitis Suppurativa: Wound Management and Beyond

Hi. I'm Dr Abigail Chaffin. I'm a plastic surgeon at Tulane University. My practice focuses on complex wound management and wound reconstructive surgery.

Our recent session at SAWC Fall focused on hidradenitis suppurativa and pilonidal cyst in sinus disease. The session was both me and Dr Hadar Lev-Tov from Dermatology. Our session focused on this very challenging set of diseases in both the multimodal team management and then for myself, the surgical management and how to achieve success. 

And so hidradenitis is a follicular occlusion disease, part of a tetrad of diseases including hidradenitis suppurativa, pilonidal cyst and sinus disease, dissecting cellulitis of the scalp, and acne conglobata. These patients are very challenging because these occur in difficult regions. With hidradenitis, we talk about typical lesions that are chronic and indurated, often fibrotic and tunneled with chronic colonization.

Typical evolution of disease with recurrence of disease or spreading of disease and, at atypical locations. Most commonly axilla, inguinal region or groin, perianal or buttock, but also extending in what I see in my practice is to adjacent regions such as the breast or difficult skin folds. The common factor being these are difficult areas to treat and heal because they have induration and maceration, contamination, shear forces, pressure forces on top of this chronic inflammatory disease and on top of this chronic colonization. So, it really takes a team-based focus to treat these patients. 

I would like to first, go over, axillary cases, which I see probably most commonly. And how I approach those is once the patient has been maximized medically by dermatology and they're tuned up medically with any comorbid diseases is to assess, do they have skin shortage or not?

We presented 2 cases in that session. One a young female who had some loose skin in the region, and how I prefer to treat those patients is a wide excision of all affected disease in the axillary region, including if it extends onto the arm or the chest wall. You need to get it all out. Then I irrigate the wounds with a a pure hypochlorous acid solution with dwell time to help eliminate any colonization. And then at that point, I put my plastic surgery hat on and decide If I can close it with like versus like tissue.

My number one technique, if there's loose skin, is local advancement of skin from the arm and the chest with multilayered closure and quilted quilting sutures with wick-assisted closure with Iotaform. This allows wide drainage, but local closure, I see them very closely in the wound clinic postoperatively to manage any wound-related complications. 

I also presented the case of a younger gentleman with extensive disease and no loose skin. This gentleman was challenging with uncontrolled diabetes, hemoglobin A1c of 13. He was smoking 2 packs a day that we had progressive education. But on him wide excision of the disease and then staged management in the wound center, smoking sensation, diabetic control, some weight loss, and then a staged skin graft procedure because he didn't have sufficient tissue to localize. 

The next cases we went through are challenging. Lady that had posterior thigh, lower abdomen, inner thigh, and groin disease. In 2 stages with the posterior thigh, which was probably a 30 cm x 20 cm I performed recycled skin grafting, which is using the dermatome first to harvest any usable skin, then excising the disease. And then since there was no local tissue for closure, placing those recycled skin grafts back on the wound after appropriate irrigation to help heal the wound without need for another donor site. She came back for a second surgery to excise the lower abdominal tissue in which I harvested extra skin, sort of spare part surgery, and then did a combination of local tissue advancement, recycled skin grafting, and complex closure, sort of the kitchen sink approach to get all of those wounds healed.

I also presented a case of very difficult tertiary disease after recurrence on a young male with severe scrotal and penile lymphedema due to lymphatic outflow obstruction and recurrent hidradenitis. This is one of the most challenging situations in which I heavily rely on my urology colleagues to operate with to locate the somatic cord and testicles to ensure the penile integrity. And then again, local tissue advancement and skin grafting as necessary. 

A few other cases that we went over [are] a breast reduction case. So many of these ladies with severe hidradenitis of the axilla extends onto the lower pole of the breast and the inframammary fold. These patients commonly have macromastia or large breast and severe symptoms from that. So mammogram, rule out any cancers, and then resect that lower pole tissue, close it in a modified breast reduction technique called the bat flap techniques, but with a modified closure with wide drainage and wick-assisted closure since we know we're starting with a colonized state. She is exceedingly happy, my happiest patient. She has resolution of her back and neck pain, resolution of her hidradenitis, because she has sort of 2 things in one. 

So those were the main cases that I went over, that run the gamut from the usual areas of axillary, inguinal, buttock, and perianal into those contiguous extension areas.

I would tell you my main point is, first, it's a team-based approach. You need your wound care colleagues. You need dermatology colleagues, primary care, and diabetic management. Once that's done, it's extensive, we pick the worst area, and we try to cure that area with resection. You need to resect all of the contiguous disease in a region. If leave it behind, it will continue to spread. And then I see them closely in the wound clinic, and I say expect some minor dehiscence. But if so, you know, we've got the wound 90% to 95% closed, and it's a short period of time in healing. Once they recover, then we go to the next area. And most challenging is the perianal and buttock region, which sometimes requires diverting colostomy.

But you can really give these patients back a quality of life. Some of these patients that have the disease everywhere have given up on life and have no quality of life and are so happy to find someone that's willing and able to treat them. It requires an army, and it requires, you know, really a coordinated approach, of medical management, infection management, plastic surgical techniques, and good postoperative care to get them healed. But they're it's a very, and they're very grateful, and it's a very rewarding surgery.