Abstract
Wide local excision is the gold standard and only potential curative therapy for recalcitrant hidradenitis suppurativa. However, high recurrence rates persist even post‐surgery with little known on the influencing factors for remission. We evaluated the effect of patient, disease, and operative factors on local cure rate of moderate to severe hidradenitis following wide local excision. We performed a retrospective chart review for all patients who had undergone surgical excision of hidradenitis at a university hospital from 2012 to 2018. We identified 79 patients with a total of 220 operative sites. The majority were obese (mean body mass index [BMI] 32.5), female (71%), African‐American (84%), and had a mean age of 31 years. A quarter of operative sites experienced a recurrence (n = 56). Patients who achieved remission had a significantly lower number of affected regions than those who experienced a recurrence (2.3 vs 3.6, P = .0023). Additionally, recurrence rate differed significantly between body locations (P = .0440). Smoking, BMI, Hurley grade, closure method, and excision size did not influence local cure rate. Surgical excision remains a worthy management option for hidradenitis patients with three quarters achieving remission after a single operation. Number of affected regions and location of hidradenitis may play a factor in recurrence.
Keywords: complications, hidradenitis suppurativa, recurrence, surgical management
1. INTRODUCTION
Hidradenitis suppurativa (HS) is a debilitating disease with a remitting‐relapsing nature. Patients present with recurrent painful nodules in intertriginous regions, which may have concurrent involvement of multiple sites.1 Recurrence of disease is costly to both the patient and provider due to multiple medical and surgical treatments, extensive hospital stays, and missed days of work.2, 3, 4 Radical surgical excision of diseased areas of skin is the gold standard for treatment of moderate to severe HS and may offer a definitive cure in some cases.4, 5, 6, 7
Although surgery can play a pivotal role in management, high recurrence rates persist even following wide local excision.7, 8, 9, 10 Patient factors, such as active smoking and body mass index (BMI), are known to exacerbate the disease,1, 11 but few studies have assessed their association with recurrence after surgery. Moreover, the role of disease factors, such as severity and location of HS with respect to disease recurrence, remains unclear.12, 13 Additionally, there is no clear treatment algorithm or consensus on the optimal surgical technique for achieving the lowest recurrence rate.5, 13, 14 Furthermore, no studies have assessed the relationship between surgical site complications and recurrence. Given the socioeconomic impact of HS, identification of factors that influence HS recurrence post‐excisional surgery may result in large cost savings.
In this study, we describe the surgical outcomes of patients who underwent wide resection of moderate to severe HS. We also evaluate the effect of patient, disease, and operative factors on local cure rates.
2. METHODS
We performed a retrospective chart review for all patients who had undergone wide surgical excision of HS at the University of Maryland Medical Center from 2009 to 2018. The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in approval by our Institutional Review Board. Incision and drainage procedures were categorised as conservative management and were not included as a definitive surgical management procedure due to (a) low efficacy and (b) recurrence that is often considered inevitable.6, 15 The same is true of surgical deroofing, which has a high recurrence rate and thought to have no role in curative treatment5 which was also excluded.
We collected data on patient characteristics, intraoperative details, complications, and readmissions within 90 days, and long‐term recurrence. The primary outcome was the local cure rate. This was defined as the absence of a recurrence of disease in the operative site following excisional surgery. Diagnosis of recurrence was ascertained through documentation of any returning rash or painful nodules at the operative site at any time after the initial operation, regardless of how the recurrence was subsequently treated. If repeated excisional surgery was required to treat the recurrence, this was defined as management of recurrence and was not considered a wound complication. The secondary outcomes were surgical site complications and unplanned readmissions related to the initial operation within 90 days. Haematoma was defined as a radiologically identified collection that required drainage. Surgical skin infection was confirmed with cultures from wound swab. We further classified complications into major and minor subtypes; major complications were those that necessitated further surgical intervention. Recurrences were not included in the definition of complication. Unplanned readmissions related to the initial operation and surgical management of complications were separate and distinct from recurrence of disease. Operative duration was defined as from the first incision until closure and placement of dressings. Length of hospital stay (LOS) was calculated based on the initial operation.
We selected active smoking and BMI as patient factors of interest as they have previously demonstrated associations with HS recurrence.13, 16 Disease factors included severity of HS and location of affected skin. The severity of HS was categorised using the Hurley grading system: mild (Hurley stage 1), moderate (Hurley stage 2), and severe (Hurley stage 3; Table 1).17 Additionally, we also utilised the number of affected body sites as another marker for disease severity.18 Excision size and method of wound closure were examined as potential influencing operative factors.
Table 1.
Hurley grading system
| Grade | Description |
|---|---|
| Stage I | Abscess formation, single or multiple, without sinus tracts and scars |
| Stage II | Recurrent abscesses with tract formation and scars, single or multiple, widely separated lesions |
| Stage III | Diffuse or near‐diffuse involvement, or multiple interconnected tracts and abscesses across the entire area |
Composite data were stored in Microsoft Excel (Microsoft 2016, Redmond, Washington, DC). We performed a statistical analysis using IBM SPSS Software Version 25.0 (IBM Corp, 2018. IBM SPSS Statistics for Windows, Armonk, NY: IBM Corp). Data were analysed using the Kolmogorov‐Smirnov test; age and BMI were found to follow a normal distribution and so mean values and standard deviation (SD) are reported. Duration of prior medical management, operative duration, size of defect, and LOS did not follow a normal distribution, so median values and interquartile range (IQR) are reported. Differences in categorical data were compared using Pearson's chi‐square tests. The student's t test was used to compare differences in BMI. Mann‐Whitney U or the Kruskal Wallis tests were used to measure differences in non‐parametric data, as appropriate. The statistical significance was set as a two‐tailed value of P ≤ .05.
3. RESULTS
We identified 79 consecutive patients for inclusion in our study (Table 2). The majority were female (71%), African‐American (84%), had a mean age of 31 (SD 11), and mean BMI of 32.5 (SD 8.0) kg/m2. Two thirds of patients had severe HS (63%, n = 50), and the rest had moderate disease burden. Additionally, all patients had undergone at least one course of failed medical or conservative management prior to surgical excision.
Table 2.
Patient demographics
| Variable | Patients (n = 79) |
|---|---|
| Gender | |
| Male | 23 (29%) |
| Female | 56 (71%) |
| Mean age (y) | 31 ± 11 |
| Mean body mass index (kg/m2) | 32.5 ± 8.0 |
| Race | |
| African‐American | 66 (84%) |
| Caucasian | 8 (10%) |
| Hispanic | 1 (1%) |
| Mixed or other | 4 (5%) |
| Smoking status | |
| Never smoker | 37 (47%) |
| Ex‐smoker | 14 (18%) |
| Active smoker | 28 (35%) |
| Prior medical management | |
| Number of patients | 79 (100%) |
| Median duration of treatment (mo) | 7.5 [IQR: 4‐13] |
Abbreviation: IQR, interquartile range.
Fifty‐seven patients had multifocal disease, which resulted in 220 operative sites (Table 3). The most common location excised was the axilla, whereas the most common closure technique was rotation advancement flap (Figure 1). The median area of disease excised was 72 cm2 [IQR: 30‐120] and did not differ significantly between body locations (Table 4; P = .3507). Operations lasted a median of 49 minutes [IQR: 36‐73] and patients stayed in the hospital for a median of 0 days [IQR: 0‐1] after the initial operation. Seven patients (54% of perineum sites) also underwent a colostomy for management of perianal disease.
Table 3.
Characteristics of operative sites
| Variable | Operative sites (n = 220) |
|---|---|
| Location | |
| Abdomen/mons | 18 (8%) |
| Axilla | 100 (45%) |
| Breast/chest | 8 (4%) |
| Buttocks/perineum/scrotum | 36 (16%) |
| Extremity (thigh, arm) | 14 (6%) |
| Groin | 44 (20%) |
| Median size of defect (cm2) | 72 [IQR: 30‐120] |
| Closure technique | |
| Direct sutured closure | 72 (33%) |
| Secondary intention | 4 (2%) |
| Delayed closure | 5 (2%) |
| Skin graft | 35 (16%) |
| Rotation advancement flap | 96 (44%) |
| Free flap | 4 (2%) |
| Mixed methods | 3 (1%) |
Abbreviation: IQR, interquartile range.
Figure 1.
Photographs illustrating the surgical treatment of an obese (BMI 33) 28‐year‐old male with Hurley grade 3 hidradenitis suppurativa. A, Preoperative image demonstrating multiple draining sinuses and fistulae. B, Intraoperative view following excision of disease skin and partial closure with local tissue rotation and advancement. The wound was later closed with a split thickness skin graft (C) 2 years after surgery with no recurrence of disease at the operative site. BMI, body mass index
Table 4.
Median size of area excised according to location of hidradenitis suppurativa
| Location | Median excision size (cm2) |
|---|---|
| Abdomen/mons (n = 18) | 38 [IQR: 18‐231] |
| Axilla (n = 100) | 78 [IQR: 48‐120] |
| Breast/chest (n = 8) | 36 [IQR: 6‐63] |
| Buttocks/perineum/scrotum (n = 36) | 85 [IQR: 28‐180] |
| Extremity (thigh, arm) (n = 14) | 72 [IQR: 30‐112] |
| Groin (n = 44) | 50 [IQR: 20‐105] |
| P value | .3507 |
Abbreviation: IQR, interquartile range.
Of the 220 operative sites, 76 wound complications occurred in 70 operative sites, yielding a complication rate of 32% (n = 70 of 220; Table 5). However, only 3% (n = 7) of complications were major and required surgical intervention; the rest were managed conservatively. Eight operative sites required unplanned readmission related to the initial operation within 90 days (4%).
Table 5.
Number and type of wound complication
| Complication | Number of operative sites (n = 220) |
|---|---|
| Wound dehiscence | 58 (26%) |
| Scar contracture | 7 (3%) |
| Surgical site infection | 5 (2%) |
| Skin graft loss or failure | 4 (2%) |
| Haematoma | 2 (1%) |
The median follow‐up duration was 33 months [IQR: 11‐47]. Following surgical excision, a quarter of operative sites experienced a recurrence of HS (n = 56). The median disease‐free interval between surgery and recurrence was 8 months (5‐23). Almost two thirds of recurrences necessitated repeated excisional surgery (63%, n = 35). We also collected details on concurrent medical HS management in the post‐operative period prior to recurrence. A significantly higher proportion of patients with a recurrence had received concurrent medical management compared with those without recurrence (46% vs 26%, P = .0036), which translated to an almost doubled risk of recurrence (RR 1.9, 95% CI: 1.2‐3.0, P = .0033). However, all patients had achieved full healing of the operative site at the end of the study period.
3.1. Influence of patient factors
First, we evaluated the effect of patient factors on recurrence and complication rates. The proportion of current smokers with recurrence was not significantly different from current smokers without recurrence (34% vs 40%, P = .4976). Similarly, there was no significant difference in the percentage of smokers with or without complications (34% vs 41%, P = .4503).
Likewise, BMI was not significantly different between those who experienced a recurrence and those who did not (31.8 ± 8.1 kg/m2 vs 32.9 ± 9.3 kg/m2, P = .4284), nor in those who experienced a complication and those who did not (31.4 ± 8.0 kg/m2 vs 33.2 ± 9.4 kg/m2, P = .1599).
3.2. Influence of disease factors
We then examined the impact of disease severity and body location on post‐operative outcomes. The proportion of patients with severe HS (Hurley grade 3) was similar between those who experienced recurrence and those who did not (80% vs 70%, P = .1175). This was also true when we compared those who experienced a wound complication and those who did not (73% vs 72%, P = .8875), that is, Hurley grade was not related to recurrence or wound complications. However, there was a significant difference in the mean number of affected body sites in the group of cured patients compared with the group who experienced a recurrence (2.3 [SD 1.8] vs 3.6 [SD 1.8], P = .0023). This was also true of complications. Patients with complications had a significantly higher mean number of affected body regions than patients without complications (4.7 [SD 2.1] vs 2.1 [SD 1.4], P = .0036).
Similarly, there was a significant difference in the recurrence rate between disease locations (Table 6; P = .0440). Operative sites on the extremities (thighs, arms) had the lowest rate of recurrence, while operative sites at the groin held the highest recurrence rate. There was no significant difference between the rates of wound complication for each location (Table 6; P = .2749).
Table 6.
Recurrence and complication rates of hidradenitis suppurativa according to location
| Location | Recurrence rate | Complication rate |
|---|---|---|
| Abdomen/mons (n = 18) | 28% | 28% |
| Axilla (n = 100) | 20% | 31% |
| Breast/chest (n = 8) | 25% | 0% |
| Buttocks/perineum/scrotum (n = 36) | 25% | 36% |
| Extremity (thigh, arm; n = 14) | 8% | 50% |
| Groin (n = 44) | 43% | 32% |
| P value | .0440 | .2749 |
Note: Bold text denotes statistical significance.
3.3. Influence of operative factors
Next, we assessed the influence of excision size and closure technique on clinical outcomes. Although the median excision size was greater in the group with disease recurrence than the group without, it did not reach significance (72 cm2 [IQR: 34‐120] vs 60 cm2 [IQR: 18‐119], P = .1416). However, operative sites with complications had a significantly larger median excision size than sites without (80 cm2 [IQR: 50‐149] vs 61 cm2 [IQR: 23‐118], P = .0036).
We excluded closure techniques with a sample size of five or fewer operative sites from this analysis due to lack of power. There was no difference in the recurrence or complication rates between operative sites closed with direct sutures, skin grafts, or rotation advancement flaps (P = .4493 and P = .7082, respectively; Table 7).
Table 7.
Recurrence and surgical site complication rates according to closure technique
| Closure technique | Recurrence rate | Complication rate |
|---|---|---|
| Direct sutured closure (n = 72) | 30% | 30% |
| Skin graft (n = 35) | 23% | 29% |
| Rotation advancement flap (n = 96) | 21% | 34% |
| P value | .4493 | .7082 |
3.4. Influence of complications
We hypothesised that a wound complication may signify incomplete excision and thus predict an HS recurrence. However, operative sites with complications were not at greater risk of a recurrence (OR 1.02 [95% CI: 0.53‐1.95], P = .9518).
4. DISCUSSION
We have demonstrated a high local cure rate of HS following wide local excision. Three quarters of HS operative sites achieved enduring remission after a single excisional operation. Additionally, the remaining sites experienced a disease‐free interval of 8 months, longer than the 6 months typically reported by studies.19, 20 These findings reinforce the utility of surgery in treating HS—surgery is the best hope for curative therapy. Interestingly, patient factors, Hurley grade, and operative factors were not found to influence the local cure rate of HS after surgical excision. However, the number of body areas affected and the location of HS may play a role in disease recurrence. The high local cure rate, long disease‐free interval, and low incidence of major complications demonstrate that surgical excision remains a worthy management option for HS patients.
There are varied reports of HS remission following excisional surgery with recurrence rates of 20% to 54% cited.7, 9, 10, 19 Interestingly, patients receiving concurrent medical HS management in the postoperative period were more likely to experience a recurrence. This effect may be a result of expectation bias, wherein physicians identify patients who are at a high risk of recurrence or more severe disease and pre‐emptively prescribe medications. Of note, disease recurrence is not a failure of surgery—it is a feature that characterises the natural course of the disease and does not affect patient satisfaction.21, 22 Wide excision is the only potentially curative therapy for HS and its impact is far‐reaching, with patients reporting improved functional status,22 increased employment,21, 23 and improved quality of life.16, 21, 24 These benefits are reported despite complications,21 recurrence,22, 25 or closure technique.24 Complications were seen in one third of the operative sites. However, the majority of the complications were minor and managed conservatively, similar to findings from other studies.7, 26, 27
Our data highlight the number of body areas affected as a potential influencing factor for recurrence that supports earlier findings.12, 25 However, Hurley grade 3 (severe hidradenitis) was not associated with recurrence. The Hurley grading system17 (Table 1) is the most commonly utilised tool for assessing HS severity, in part due to its simplicity and ease of use. However, it is not a quantitative metric and its three stages are based on static disease characteristics. Therefore, it may not capture the widely variable clinical presentation of HS. Furthermore, it possesses limited value for monitoring the efficacy of medical and surgical interventions.12, 28 Given our findings, the number of body sites may have increased utility over Hurley grading when assessing the risk of recurrence post‐excisional surgery.
Comparison of HS location revealed a significant difference in recurrence rates. The groin region held the highest rate of recurrence in accordance with the literature19, 29 which reports the rates of 37% to 40%. We also noted that the extremities possessed the lowest recurrence rate. This differential recurrence rate may be linked to the extent of excision, which requires a fine balance between the creation of an excessively large defect and disease recurrence. Regions with functional or aesthetic priorities (axilla, groin, and perineum) may limit resection vs other areas (thigh and forearms) where complete resection with sufficient margins can be more easily achieved. In addition, the extremities are atypical sites for HS, which is typically limited to hair‐bearing areas, such as the axilla, and these atypical regions often experience fewer recurrences.
Prior studies have found an association between recurrence and active smoking or BMI13, 16; however, this relationship was not observed in our study. This may be due to confounding factors such as weight loss and smoking cessation in the postoperative period. Weight loss and smoking cessation favour longer remission periods30 and may play a more significant role in the prevention of recurrence of HS than surgical treatment alone.13 Details on smoking status and BMI were collected at the time of surgery, and consequently do not reflect any post‐operative lifestyle changes.
In terms of operative factors, we did not observe any association between excision size or closure method with disease recurrence. Recurrence has been linked to incomplete resection of diseased areas.13, 29 Therefore, it would be expected that an inverse relationship exists between the extent of resection and disease recurrence. However, this was not observed in our cohort. Excision size was greater in the cured operative sites but did not reach significance. This may be secondary to the heterogeneity of the clinical presentation of HS in which diseased areas ranged from 12 to 1400 cm2 in our study. One of the challenges in resecting HS is that it is impossible to visualise the abnormal apocrine sweat glands that will ultimately lead to the diseased skin, but rather only the sequelae of these diseased sweat glands, such as chronic sinuses, scarring from past disease, and current abscesses. Simply removing the patches of skin that have evidence of past or current HS, of course, does not guarantee that the adjacent skin will not develop the disease in the future. A disadvantage in taking wider margins is the increased wound size and the corresponding increased morbidity and complexity of the closure vs a decrease in the likelihood of recurrence. At this time, there is no good way to quantify the appropriate margins that would lead to lower recurrence and it is the preference of the authors to remove all evidence of visual disease with the understanding that this will remove the majority of the diseased sweat glands. The optimum closure method following wide resection of HS remains controversial, and there is still no consensus despite an abundance of studies investigating the effects of closure technique on recurrence.5, 7, 9, 13 We believe that the method of closure is more likely influenced by disease location, the extent of resection, and the size of the resultant defect, and therefore did not influence disease recurrence. The method of wound closure chosen should be appropriate for the defect size while minimising complications.
This study is limited by its retrospective nature, single‐centre cohort, and the heterogeneity of patients. However, it is strengthened by its large sample size and long follow‐up period. Additionally, our patient demographics were consistent with those found in the literature.1, 31 Therefore, our results are representative of HS surgical patients. Future studies may include large longitudinal cohort studies to evaluate for causative factors. Additionally, future investigations may assess the cost‐effectiveness of surgical management for recalcitrant HS.
The high local cure rate, long disease‐free interval, and low incidence of major complications demonstrate that surgical excision remains an excellent management option for HS and holds the potential for lasting disease control. Patient factors, Hurley grade, and operative factors did not influence the local cure rate of HS after surgical excision. However, the number of body areas affected and location of HS were highlighted as potential risk factors for recurrence.
CONFLICT OF INTEREST
The authors declare no potential conflicts of interest.
Ngaage LM, Wu Y, Ge S, et al. Factors influencing the local cure rate of hidradenitis suppurativa following wide local excision. Int Wound J. 2020;17:117–123. 10.1111/iwj.13241
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