Accelerated wound healing after wide excisions in Hidradenitis Suppurativa using autologous split‐thickness skin grafting and platelet‐rich plasma

Dear Editors,

Hidradenitis suppurativa (HS) is a chronic, recurrent, inflammatory debilitating skin disease that is characterised by painful, deep‐seated, inflamed boils, sinus tract formation, and scarring, mostly in the flexural body sites.

To date, there is no long‐term cure for HS, and the treatment strategy usually consists of both medication and surgery 1. In chronic, severe HS [Hurley stage III with >1% body surface area (BSA) affected 2], systemic drug therapy, such as oral antibiotics or TNF‐α inhibitors, with adjuvant surgery is needed to achieve remission 1. Surgery includes wide excision of the entire affected area, with removal of sinuses and associated inflamed and scar tissue 3.

Several techniques have been described to close the large surgical defects in HS. Long‐term results showed no difference in the recurrence rate between a variety of reconstruction methods 4. Local wound reconstruction is crucial for accelerating the healing of post‐surgical skin defects and thus preventing prolonged healing times. However, there still is no consensus on which reconstructive technique (e.g. healing by second intention, closure with skin grafts or local flaps) to use, and there is even less experience with topical bioactive agents 5.

Platelet preparations, such as platelet‐rich plasma (PRP) and platelet‐rich fibrin matrix (PRFM), have been used to deliver growth factors directly to wounds 6. The actions of PRP include promoting tissue regeneration by induction of newly synthesised collagen, elastin dermal extracellular matrix and neoangiogenesis 7. To date, only one case has been reported whereby PRP and Hyalomatrix gel have been used with good results after extensive HS surgery 8.

Questions addressed

Surgery is the only curative option in advanced severe HS (Hurley stage III). However, in such cases, large defects are created by wide local excision and healing by secondary intention, which often lead to prolonged healing times. The objective of this case series was to determine the clinical outcome and wound‐healing time after wide surgical excision of advanced HS lesions followed by split‐thickness skin grafting (SSG) in combination with topical autologous PRP.

Cases

The surgical excisions were performed between August 2014 and November 2015 in the department of Dermatology in the Erasmus University Medical Center in Rotterdam. Data were retrospectively extracted from the medical records. The first procedure was performed at the urgent request of case 2, who was a crane operator in the port of Rotterdam. He was at the point of being discharged from his job because of absenteeism from work as a result of his HS. He asked for the most rapid possible healing time in order to keep his job.

All surgical procedures (wide local excisions) were performed under general anaesthesia. Before excising the HS‐affected skin, SSGs were taken from the affected area, meshed in a 1:1·5 ratio and stored in saline‐moistened gauzes in sterile plastic jars in a refrigerator at 4°C. The HS‐affected skin was then radically excised down to the subcutaneous fat and left for granulation tissue formation. Wound care consisted of a twice‐daily rinse, with the subsequent use of iodine ointment and non‐adherent dressings. One patient used fusidic acid 2 mg/g cream and chlorhexidine/cetrimide as alternative antibacterial topical agents because of an allergy to iodine.

Fourteen days after surgery, a PRP and SSG procedure was performed. From each patient, 18 ml autologous peripheral venous blood was collected in citrate tubes and centrifuged at 400 g (10 minutes), after which 30% of plasma volume was removed, followed by a second centrifugation step at 1200 g (10 minutes), both at room temperature. Thereafter, half of the obtained PRP solution was applied on the wound bed, and the wound surface was subsequently covered for at least 80% with meshed autologous SSG, which was obtained from either the excised skin (cases 2–4) or the thigh (case 1). At last, the residual PRP was applied on top of the SSG and activated by autologous serum, leading to the entrapment of the SSG in a thrombin‐fibrin gel, with firm adherence to the wound bed. Concomitant systemic medication for HS in all subjects consisted of triple oral antibiotic therapy, either clindamycin 300 mg BID or moxifloxacin 400 mg QD, rifampicin 600 mg QD and metronidazole 500 mg QD 9, 10, 11, 12, 13. The combination of antibiotics was administered for at least 10 weeks preoperatively and 10 weeks postoperatively.

Wound‐healing time and recurrence rate were closely monitored by clinicians, initially every 2 weeks and after 2 months every 4 weeks until the transplanted area was healed. Moreover, the course of wound healing was recorded by digital photography. Written informed consent for the use of patient data and photographs was obtained from all subjects in accordance with the Declaration of Helsinki.

Results

Four HS patients were identified from the records, all males, with a median age of 35 years, ranging from 31 to 47, and displaying Hurley stage III disease (Table 1). None of the patients were obese, while two patients were overweight based on their body mass index (BMI). Three of four patients were active smokers during the period of wound healing, and none of the patients was suffering from diabetes. The area of surgery involved the gluteal skin (three cases) and the scalp (one case). The latter involved dissecting cellulitis of the scalp of a patient with HS in other body sites unresponsive to all thinkable (combination) therapies, including anti‐TNF‐α. Dissecting cellulitis is considered an ectopic form of HS. The median surface of the excised skin was 737 cm², ranging from 336 to 1500. There was a follow‐up period of at least 9 months assessing the clinical outcome. No complications, such as postoperative bleeding, wound infection or skin contracture that might limit the motion of the lower limbs were seen. The median wound‐healing time after the initial surgical procedure was 110 days (range 48–114 days). Several stages in the course of wound healing are illustrated in Figure 1. One patient (case 2) needed a second excision under local anaesthesia after 2 months because of a persistent perianal lesion of 15 cm² with underlying sinus (Figure 2).

Table 1.

Summary of patient characteristics with details about surgical procedures and wound healing

	Case 1	Case 2	Case 3	Case 4
Age (years)	30	32	31	47
Gender	Male	Male	Male	Male
Skin type (Fitzpatrick)	VI	II	VI	II
Smoking status	Current	Past	Current	Current
Diabetes mellitus	No	No	No	No
Body mass index (kg/m2)	21·0	27·0	21·2	28·6
Concomitant systemic	Triple AB*	Triple AB	Triple AB	Triple AB
HS medication	Prednisolone	Anti‐TNFα	Prednisolone	Prednisolone
Area of surgery	Scalp	Gluteal	Gluteal	Gluteal
Surface of surgery (cm2)	1024	450	336	1500
Number of surgical interventions†	1	2‡	1	1
Wound‐healing time (days)§	114	107	48	114

PRP, platelet‐rich plasma; SSG, split‐thickness skin grafting.

^*Triple AB, triple oral antibiotic therapy; either clindamycin 300 mg BID or moxifloxacin 400 mg QD, rifampicin 600 mg QD and metronidazole 500 mg QD.

^†Wide excision and SSG/PRP.

^‡Second small excision because of a local persistent lesion of 15 cm².

^§Based on clinical assessment and photography during follow‐up.

Figure 1.

Case 1 A, B, C. Course of the wound healing (1A) presentation before surgery, (1B) 5 days after wide excision, (1C) the result after 6 months. Case 2 A, B, C. Course of the wound healing (2A) presentation before surgery, (2B) 6 weeks after wide excision, (2C) the result after 6 months. Case 3 A, B, C. Course of the wound healing (3A) presentation before surgery, (3B) 14 days after wide excision, (3C) 48 days after wide excision. Case 4 A, B, C. Course of the wound healing (4A) presentation before surgery, (4B) 2 days after wide excision, (4C) 114 days after wide excision.

Figure 2.

Case 2 in prone position with a persistent lesion at the cranial end of the natal cleft, (A) overview with a perianal sinus, (B) the sinus in detail.

Conclusions

The clinical outcome of wide surgical excision with additional use of topical PRP and SSG reconstruction in advanced HS provided satisfactory results. All patients were cured of their local disease, and complete healing of the large wounds was achieved in 48 days to less than 120 days. The second case could retain his job as a crane operator at the port.

Although the outcome might have been negatively affected by the smoking and the use of prednisolone in three cases, the concurrent use of systemic antibiotics, or anti‐TNF‐α, could have enhanced the wound healing. Advantages of the used techniques include less pain because there was no erosive donor area by harvesting SSG specimens from lesional skin that would become waste material (except for one case harvesting from healthy skin), and there was no need for the application and removal of sutures (except for one case using self‐dissolving stitches).

Despite the variability of surgical techniques, the general consensus on the preferred treatment for advanced HS is excisional surgery. A recent systematic review describes lower recurrence rates with wide excision using skin flaps or skin grafts as the closure methods 14. Moreover, in the gluteal and perianal regions, complete wound healing after wide surgical excision with the use of (delayed) skin grafting was accomplished faster than wounds left open for secondary healing 15, 16. In conclusion, the use of autologous SSG (from lesional HS skin that would become waste material) with the complementary application of PRP is a simple, inexpensive closure technique reducing peri‐surgical morbidity and pain and to speeding up recovery after extensive HS surgery.

Allard RJV Vossen1, Hessel H van der Zee1 & Errol P Prens1
1Department of Dermatology
Erasmus University Medical Center
Rotterdam, The Netherlands
a.vossen@erasmusmc.nl