Guidelines hidradenitis suppurativa
Updated on august 2019
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Surgery is to be considered systematically within a medical and surgical concertation meeting.
Surgery can be chosen depending on clinical presentation, as an urgent measure for abscesses, or can be scheduled in other cases.
For a fluctuant abscessed nodule: urgent incision and drainage or deroofing with a biopsy punch are indicated for immediate pain relief. This is not a definitive treatment and relapses are frequent.
For a Hurley stage Ⅰ persistent cold nodule, or Hurley stage Ⅱ sinus tracts (tunnels, fistula), the following can be envisaged:
complete excision limited to the lesion, with or without direct suture. Relapse rates vary from 40 % to 70 %;
or marsupialization (deroofing) with ablation of the lesion: this makes it possible to preserve healthy skin; this can be followed up with controlled wound healing. Relapse rates vary by study from 20 % to 50 %.
These types of excision are most often performed under local anaesthesia, tumescent if necessary, and can therefore be performed by dermatologist expert in dermatological surgery.
For a scar mass, Hurley stage Ⅱ bands or particular stage Ⅲ bands, a wide excision under general anaesthesia is suggested: a wide (1-3 cm) and deep safety margin of healthy skin is recommended. Loss of substance should not be reduced to facilitate reconstruction.
Surgical incision performing away from nodular lesions and sinuous tracts (Hurley stages Ⅱ and Ⅲ) with deep safety margin in healthy skin space for complete removal.
Direct suturing is generally impossible and the wound must be closed either by controlled healing or by thin or flap skin graft. Wide excision has better therapeutic results, with the lowest rate of relapse in the area treated (0-15 %). It involves prolonged local post-operative care. In the long term, there is a risk of retractile scars (in particular axillary contractures, vulva widening, stenosis or anal incontinence) which should be anticipated by posturing and physiotherapy.
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