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HIDRADENITIS SUPPURATIVA

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SUMMARY

  • Local cure of HS can be accomplished with elective surgical procedures.

  • Surgery is indicated throughout all stages of hidradenitis suppurativa, with the exception of the mildest forms.

  • Surgical interventions for HS include intralesional injection of triamcinolone, incision and drainage, deroofing, and excisional surgery (including CO2 laser).

image Beginner Tips

  • Cryoanesthesia with liquid nitrogen or a refrigerating spray is useful, as the inflamed area is difficult to anesthetize using injectable anesthetics.

  • Cryoanesthesia should be performed over the full length of the planned incision or injection site.

  • Acute surgical interventions, that is, intralesional injection of triamcinolone and incision and drainage, can be performed to quickly relieve symptoms of inflammatory nodules and tense abscesses.

image Expert Tips

  • Secondary intention healing is ideal as it obviates the risk of entrapping diseased skin leading to recurrence.

  • The extent of sinus tract formation can only be established intraoperatively, and the affected area is often considerably larger than expected based on the preoperative assessment.

  • The addition of color Doppler ultrasound may add relevant information prior to surgery.

image Don’t Forget!

  • Photodynamic therapy (PDT) may be useful in the treatment of HS through selective, cytotoxic, and immunomodulatory effects.

image Pitfalls and Cautions

  • Patients with HS in the perianal or perineal area, especially male patients and those with concomitant intestinal bowel disease (IBD), are at risk of developing fistulas penetrating through the anal sphincter complex or communicating with the rectum. The presence of trans- or intersphincteric sinuses or fistulas should preferably be assessed by endorectal MRI or a fistulogram preoperatively.

image Patient Education Points

  • Patients should appreciate that HS is a chronic disease, and that any intervention runs the risk of potentially serious side effects.

  • To ensure the best patient outcomes, surgeons should select the appropriate surgical technique based upon operator experience and the individual needs of the patient.

  • Patients should be highly motivated prior to initiating HS surgery, as recovery times may be protracted and require significant wound care and physical therapy.

image Billing Pearls

  • Hidradenitis excision may be coded with the 11450-11471 series codes.

INTRODUCTION

Hidradenitis suppurativa (HS), also known as acne inversa, is a chronic, recurrent, inflammatory and debilitating skin disease that usually presents after puberty. HS is characterized by painful, deep-seated, and inflamed boils most commonly in the axillary, inguinal, and anogenital regions.1 HS is a common disease, with an average prevalence of 1% in Europe and a male-to-female ratio of 1:3.2–4

The pathogenesis of HS is still not completely understood. The disease probably originates from keratinous plugging of the infundibulum, resulting in dilatation and subsequent rupturing of the hair follicle. The expulsion of keratin fibers and commensal bacteria into the dermis upon rupture of the hair follicle leads to a severe foreign-body like immune response, resulting in inflammatory nodules and abscesses.1,...

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