Surgical and Laser Management of HS
A range of surgical treatments is available to patients with early localized lesions or persistent more widespread disease not prevented or controlled with medical therapy.
Current active options include:
- Mini unroofing of individual inflamed follicular units
- Unroofing (Deroofing)3 and scrupulous eradication of the subcutaneous gelatinous mass and sinus tracts with secondary intention healing or delayed reconstruction. Scissors, electrosurgery, CO2 laser, or scalpel are used for this work.
- Excision of the entire area followed by secondary intention healing (leaving the area open until it heals on its own) or primary closure (stitches or staples), grafting, or flap repair. The excision of a given area may also be accomplished by means of CO2 laser.1 Typically, traditional surgical excision by a general surgeon or plastic surgeon is done usually in a hospital operating room under general anesthetic, and may be followed by a hospital stay. Laser based excision is often performed under local anesthesia by dermatologists or surgeons. Surgical excision often provides permanent relief to those with advanced disease whose other options have run out.
- Incision and drainage (lancing or ‘I&D’) is occasionally needed to relieve acute pressure and pain. It is discouraged as definitive therapy because of inadequate clearance of the subcutaneous gelatinous mass and the sinuses. Failure to obsessively clear this material frequently leads to recurrences. If employed for emergency pain relief I&D is best followed within hours or days with full unroofing followed by healing by secondary intention (which takes weeks but gives excellent results).
Other options less used include:
- Cryosurgical destruction – Using Liquid Nitrogen (LN2) to freeze individual lesions or sinus tracts is an experimental procedure recently introduced.
- Electrosurgical destruction can be used on individual nodules as well as for extensive deroofing.
- Laser used with a destructive setting can also be used for individual lesions as above.
- Laser – non-destructive (hair removal) treatments, best performed with a Nd-YAG laser,2 will cool active nodules and may prevent the eruption of new lesions in the treated area.
As you can see from the large number of treatments available, management must be chosen with care for each patient, with selection determined by the individual lesion type, the stage of disease, the skill and experience of the operator, and the response to past and concurrent preventive management.
- Hidradenitis suppurativa: successful treatment using carbon dioxide laser excision and marsupialization. Hazen PG, Hazen BP. Dermatol Surg. 2010 Feb;36(2):208-13. doi: 10.1111/j.1524-4725.2009.01427.x. Epub 2009 Dec 21
- Randomized control trial for the treatment of hidradenitis suppurativa with a neodymium-doped yttrium aluminium garnet laser. Tierney E, Mahmoud BH, Hexsel C, Ozog D, Hamzavi I.Dermatol Surg. 2009 Aug;35(8):1188-98. doi: 10.1111/j.1524-4725.2009.01214.x. Epub 2009 May 12.
- Commentary: unroofing for hidradenitis suppurativa, why and how.
- Danby FW.J Am Acad Dermatol. 2010 Sep;63(3):481.e1-3. doi: 10.1016/j.jaad.2010.01.033