As a dermatologist, I love procedures. There is just something about the doing and using of your hands to help someone that is professionally satisfying. For decades, we’ve approached different dermatologic conditions like hidradenitis suppurativa (HS), as procedure centered. Over time, as our understanding of HS grew along with the discovery of biologics, HS is primarily a medically treated condition. But that doesn’t mean that procedures fall to the wayside. Now, they are often supplemental or adjunctive to biologic therapy, but for limited disease, they may also be primary. In addition, many patients benefit from a combination approach, with using systemics to reign in disease activity and then procedures as a complement to tackle resistant areas or flares.
The most basic procedure is often performed by HS patients at home, where they simply drain their lesions. But with active inflammatory nodules, abscesses or persistently draining tunnels, other procedures may offer benefit. An oldie but goodie is incision and drainage (I&D). Often chosen to relieve pain and allow drainage, I&D can offer short term relief from pressures and pain. The downside is that recurrences can happen and it doesn’t treat the underlying HS inflammatory process. For inflammatory nodules, intralesional corticosteroids, often triamcincolone, are used to knock inflammation back and provide relief. Quick and inexpensive, intralesional steroids are effective and used regularly to keep lesions in check.
One of the more popular treatment options is deroofing, a simple process where the “roof” or top of an established HS tunnel is removed. The basic concept is that this procedure converts a closed tunnel into an open wound that can heal from the bottom up. Deroofing is a relatively quick, cost-effective method to shut down persistent tunnels and is particularly useful when there is a defined sinus tract. It can potentially reduce recurrence and is also tissue sparing compared to other excisional procedures. In my experience, patient satisfaction is often high with this procedure, and it can help stop draining tunnels where medical management often stalls. While cutting the roof is an option, so is freezing it. Cryoinsufflation is another method of tunnel destruction that injects liquid nitrogen directly into HS sinus tracts to freeze and collapse the tunnels from the inside out.
When deroofing isn’t enough, often excision is chosen. Excision can be local or limited or more extensive for widespread disease. Excision can help with multiple interconnected tunnels and in situations with extensive scarring. Part of the challenge with excision is the risk of complications including recurrence, infection and scarring, which is also one of its goals. Reconstruction after excision can also be complicated with wound healing and discomfort.
Now one procedure you might not immediately associate with HS is laser hair removal. The hair follicle is part of the pathogenesis in HS, so targeting it makes sense. With laser hair removal, the hair follicle is destroyed which may reduce HS symptoms. This is often useful for locations like the inner thighs or armpits. Part of the drawback is the lack of insurance coverage, multiple treatments needed, and side effects like pigmentation change with darker skin types. In addition to laser hair removal, HS may also be treated with Nd:YAG or CO2 lasers, with the goal of physical destruction and ultimate end game of scarring. Availability, provider preference and cost factor into device selection so laser utility can vary.
And yes for you Botox lovers out there–Botulinum toxin has also been studied and used for HS. Botox reduces sweat (which aggravates HS), decreases inflammation and can also help with pain.
Trotter’s Take: Procedures for HS are not a last resort but rather an important component of a multidisciplinary HS plan.
Want to go under the knife a little more for HS? Then check out my podcast with Dr. Nader Abdoul Fattouh, as he outlines procedures in his clinic for HS.
