35-Year Experience with Surgical Treatment of Hidradenitis Suppurativa

Hidradenitis suppurativa is a painful and disfiguring chronic inflammatory condition affecting both men and women. Medical treatments, such as antibiotics and immunosuppressive agents, are often ineffective. Over time, patients can suffer from recurrent abscesses, chronic purulent drainage, scarring, and contractures that can only be corrected by surgical excision. There is no agreement, however, on the best way for the surgeon to manage this condition. The purpose of this review is to describe the results of surgical treatment of this condition in a large cohort of patients managed by local excision of hidradenitis, healing by secondary intention and reoperation as needed.

A retrospective review was conducted of all patients operated on by the author for hidradenitis over a 35-year period. Specific data abstracted included patient age, weight, admission, length of stay, wound size, type of wound care, number of post-op visits, time to heal, and recurrence. Most wounds healed by secondary intention and were managed using simple tap water-moistened plain gauze dressings changed three times a day.

From 1979 through 2014, 122 patients (56 men and 66 women), median age 38, underwent 245 operations for hidradenitis suppurativa. Patients underwent from 1 to 10 procedures; 61 patients (50%) underwent two or more procedures; and 26 (21%) underwent three or more. Wound sizes at operation ranged from quite small to over 1500 cm². Men were older (42 vs 34 years, p < 0.001) and had larger median wound size (98 vs 55 cm², p < 0.001). A total of 197 wounds healed by secondary intention: 83 of these (median size 159 cm²) were left completely open at the time of surgery; 117 (median size 100 cm²) were partially closed. A total of 30 wounds (median size 38 cm²) were closed primarily; 15 (median size 196 cm²) were closed by skin graft. Patients undergoing 139 procedures were admitted to the hospital for the initial wound care. Their median combined total wound size was 160 cm²; length of stay was 5.5 days; and median time to heal was 60 days. In total, 106 procedures were ambulatory; median wound size was 30 cm²; and median time to heal was 40 days. Recurrent or new disease was common, with some patients requiring multiple procedures over many years to maintain control of symptoms. Although wound healing can take up to several months, patients quickly learned how to care for themselves and were usually pain-free after the first two or three weeks.

Surgical treatment of hidradenitis suppurativa by wide local excision with healing by secondary intention using tap water-moistened plain gauze dressings changed 2-3 times per day is a simple, practical approach that has good results. Recurrence of disease is common and should not be thought of as a failure of surgical treatment, but rather as a feature of the disease that must be anticipated and managed.