Treatment & Surgery

Treatment of HS has been difficult and unsatisfactory in the past. Treatment now is directed at prevention of new lesions through medical management and elimination of existing lesions. Medical therapies, including antibiotics, antiandrogens, and retinoids, have better success in prevention or treatment of early isolated lesions; established sinus tracts and extensive lesions of advanced cases respond only to en bloc surgical excision.

Wide excision of the entirety of the affected areas is the only known curative treatment for hidradenitis suppurativa. The key to eliminating recurrent disease is to completely excise the affected area with a 1- to 2-cm margin, so that the defect edges are free of disease. It is also important to assure an adequate depth of excision: surgery should extend to the level of the fascia or include at least 0.5 cm of subcutaneous fat to ensure removal of the full apocrine ductwork.

In wide excision surgery, the question then arises of how to provide adequate skin coverage. Allowing the area to heal by secondary intention after wide excision can be an acceptable option, especially in the perianal areas. Application of a split-thickness skin graft can be done either immediately following excision or in a staged fashion. This technique allows coverage of large defects but can be associated with significant wound healing problems at the donor and recipient sites, graft failure, and a poor cosmetic result. Skin grafting areas in and around the anal canal is contraindicated because of the risk that anal stenosis will develop. Finally, even with wide excision, complete closure can often be achieved by widely elevating surrounding tissue and advancing that tissue into the defect until coverage is established.