Study Highlights Impact of Smoking on Surgical Outcomes for HS

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A new systematic review suggests that there is insufficient evidence for a course of action related to smoking and hidradenitis suppurativa (HS) surgical outcomes, given an apparent weak association between smoking and poor HS surgical outcomes.¹

This review was authored in part by Akash Rau, an MD candidate from the department of medicine at Michigan State University College of Human Medicine. The investigators noted that there is a range of surgical treatments for individuals with HS, from deroofing to surgical excision.²

These surgeries can also vary in extent, from lesional to regional. Rau et al. also highlighted prior data suggesting smoking and obesity are closely linked to HS.³

“There are limited studies assessing this relationship,” Rau and colleagues wrote. “Therefore, we conducted a systematic review to identify randomized controlled trials, observational studies (cohort, case–control, and cross-sectional), or case series with ≥5 patients that assessed the impact of tobacco on surgical outcomes in HS.”¹

Trial Design

The investigative team conducted a search for their systematic review, including terms in their assessment such as “hidradenitis suppurativa” combined with phrases such as “surgery” or “acne inversa” with “surgery.” The team’s review search yielded a total of 4348 articles.

They conducted their systematic review in December 2022, conducting their search through the databases PubMed, Embase, Scopus, and Web of Science. The team removed 1846 duplicates, with 2502 articles remaining.

At this point in the review process, 363 were given full-text review and, by the next stage, there were 22 articles that met the investigators’ criteria for inclusion. Among these 22 studies, 16 included statistical analyses of outcomes associated with smoking status and 6 provided data on smoking without any statistical analyses.

Among the research team’s 22 articles, it was noted that 13.6% were labeled as case series, 82% were cohort studies, and 4.5% had been case–control studies. In all, these studies and their results covered 3104 trial participants, with 1539 being identified as cigarette smokers. The investigators added that a single study did not differentiate between those who were current and former smokers.

Findings

Among the 16 analyses that involved use of statistical analyses, data from 2831 patients were included. The investigative team found that smokers made up 51.6%. Notably, none of these studies found a statistically significant link between poor surgical outcomes and smoking.

Conversely, the researchers noted that the 6 studies without statistical analyses, the subjects of which were 61.8% smokers, resulted in higher rates of complications in those labeled as smokers compared to those who did not smoke.

The team specifically found that delayed HS recurrence rates had been 20.6% for smokers versus 5.45% for those who did not. Additionally, healing of wounds was found to have occurred among 3.1% versus 0%, respectively. They also found that dehiscence rates were 5.2% versus 0%, respectively.

Overall, the investigators noted that tobacco cessation is still generally advised 1 to 2 months prior to any HS-related surgical procedures. Nevertheless, they stressed that evidence in their review of these studies linking smoking to poorer surgical outcomes continues to be limited.

Importantly, the research team did note that none of the studies controlled for factors such as participants' sex, age, race, the size and location of HS lesions, or HS stagning. They also found that other variables, such as comorbidities, had also not been accounted for.

“Limitations include a lack of standardized definitions of surgical outcomes in HS, for example, local recurrence or disease recurrence at a distant site,” they wrote. “Further studies with matched patients can further analyze the association between smoking and surgical wound healing in HS patients.”¹

References

1. ^{Rau A, Bazzi M, Elhage KG, Daveluy S. The association between smoking and wound healing after surgical treatment of hidradenitis suppurativa: a systematic review. Int J Dermatol. 2024 Dec 13. doi: 10.1111/ijd.17613. Epub ahead of print. PMID: 39670527.}
2. ^{Bui H, Bechara FG, George R, Goldberg S, Hamzavi I, Kirby JS, et al. Surgical procedural definitions for hidradenitis suppurativa developed by expert Delphi consensus. JAMA Dermatol. 2023; 159(4): 441–447. https://doi.org/10.1001/jamadermatol.2022.626.}
3. ^{Alotaibi HM. Incidence, risk factors, and prognosis of hidradenitis suppurativa across the globe: insights from the literature. Clin Cosmet Investig Dermatol. 2023; 16: 545–552. https://doi.org/10.2147/CCID.S402453.}