Hidradenitis Suppurativa: Role of Surgery

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Robert G. Micheletti, MD: I think management of hidradenitis is really best thought of as an interdisciplinary collaborative approach. The dermatologist is there to help manage the disease, particularly when it's more moderate or severe, and the primary care doctor is there to think about some of these risk factors like diabetes, metabolic syndrome, cardiovascular risk, things that can be addressed systemically. Sometimes surgeons, infectious disease, gynecology, nutrition, and endocrinology are there. There's a role sometimes for a particular patient for each of these disciplines. And when we talk specifically about surgery, sometimes you hear it said that hidradenitis is really a surgical disease. I think what people mean by that is that you often cannot totally cure the disease unless you cut it out. I think that may be less true now that we have some better drugs to treat hidradenitis. But what people are saying is that whenever you have a predisposed patient who has pilosebaceous units that have the ability to be affected, you can see hidradenitis coming back. So, when we talk about surgeries, and there is a role for surgery, we have to know what we're getting ourselves into. The rate of recurrence from surgical incision is directly related to how much tissue is taken out. A smaller surgery that's easier to tolerate and easier to recover from is more likely to result in recurrent disease. Whereas a large excision that's often very difficult for the patient and can be highly morbid, that's the surgery that may lead to a "cure."

I think when we're talking about surgery, thinking about surgery, or finding a surgeon who's willing to operate on patients, we really have to know what we're sending them to and what we're getting ourselves into. Now, that being said, there are some minor surgical procedures that can be useful. I think some of these are things that dermatologists do at the bedside, like the long-pulse Nd:YAG (neodymium-doped yttrium aluminum garnet) laser to treat individual active lesions. Think of it as a laser hair removal, destroying that follicular unit. That has been shown in the literature to be effective in split body studies. The CO laser, for some individual providers who are comfortable with that, that can be used actually to excise an entire area. And that is a somewhat large procedure, but, actually, the results are quite good. There's something called the mini-unroofing procedure where the provider will use a punch biopsy to remove an inflammatory nodule and then essentially scrape the base with gauze and forceps, and let it heal by secondary intention. That is preferred really to incision and drainage because with incision and drainage, you might relieve acute inflammation and acute pain, but that lesion is still there, and it can recur. Whereas something like the mini-unroofing procedure can not only relieve that pain that's happening right then, but also remove the lesion in its entirety. There are other things like unroofing of sinus tracts and so on that maybe require a little bit more knowhow, but are not that difficult to do at the bedside.

The last thing that I would say, from a procedure or surgical standpoint, is something pretty simple that a lot of dermatologists do, which is just injection of triamcinolone intralesionally. So, injecting 10 mg/mL of triamcinolone into an inflamed lesion, that can result in relief over the course of a day or two. And even though we've known this anecdotally to be the case, there is some emerging literature supporting that as something that really does make a difference. I think there are a lot of surgical things in our armamentarium that may be appropriate in selected cases, but I would emphasize that a good medical regimen to prevent recurrence and to bring down the overall inflammation is an important and vital aspect of treatment with these patients.

Transcript Edited for Clarity