University of Groningen

Hidradenitis suppurativaDickinson-Blok, Janine Louise

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Citation for published version (APA):Dickinson-Blok, J. L. (2015). Hidradenitis suppurativa: From pathogenesis to emerging treatment options.[Groningen]: University of Groningen.

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97

7SKIN-TISSUE-SPARINg ExcISIoN wITH ELEcTRoSURgIcAL PEELINg (STEEP): A SURGICAL TREATMENT OPTION FOR SEVERE

HIDRADENITIS SUPPURATIVA HURLEY STAGE II/III

J.L. Blok1, MD; J.R. Spoo1, MD PhD; F.W.J. Leeman2, MD; M.F. Jonkman1, MD PhD; B.

Horváth1, MD PhD

1Department of Dermatology, University of Groningen, University Medical Center Groningen,

Hanzeplein 1, 9700 RB Groningen, the Netherlands2Department of Dermatology, Antonius Hospital, 8601 ZK Sneek, The Netherlands

Published in the Journal European of the Academy of Dermatology and Venereology,

2015;29:379-82

98

ABSTRAcT Background: Surgery is the only curative treatment for removal of the persistent sinus tracts in

the skin that are characteristic of severe hidradenitis suppurativa (HS). Complete resection of

the affected tissue by wide excision is currently regarded as the preferred surgical technique in

these cases. However, relatively large amounts of healthy tissue are removed with this method

and suitable skin-tissue saving techniques aiming at creating less extensive surgical defects are

therefore needed in severe HS.

Method: We describe a skin-tissue saving surgical technique for HS Hurley stage II-III disease:

the Skin-tissue-sparing Excision with Electrosurgical Peeling (STEEP) procedure.

Discussion: In contrast to wide excisions that generally reach into the deep subcutaneous

fat, the fat is maximally spared with the STEEP procedure by performing successive tangential

excisions of lesional tissue until the epitheliazed bottom of the sinus tracts has been reached.

From here secondary intention healing can occur. In addition, fibrotic tissue is completely

removed in the same manner since this also serves as a source of recurrence. This tissue sparing

technique results in low recurrence rates, high patient satisfaction with relatively short healing

times and favorable cosmetic outcomes without contractures.

99

INTRoDUcTIoNHidradenitis suppurativa (HS) is an inflammatory skin disease characterized by painful deep-

seated nodules and abscesses that mainly occur on apocrine gland bearing skin.1 In a later

stage, sinus tracts surrounded by extensive fibrosis are formed in the dermis that in severe

cases even extend into the deep subcutaneous fat. These sinus tracts serve as a source for the

characteristic chronically recurring inflammation in HS. The Hurley classification is frequently

used to reflect disease severity by determination of: (i) the character of the lesions (solitary

nodules or abscesses correspond to stage I disease while stage II/III disease is characterized

by sinus tract formation); and (ii) the extensiveness of the lesions (differentiation of stage II

from stage III disease is made by determining whether or not there is healthy skin between the

lesions).2

Despite the numerous therapeutic options it is still difficult to treat HS, especially in severe

cases (Hurley stage II or III disease). Severe HS is characterized by both inflammation and a

permanent destruction of the normal skin architecture by the epithelialized sinus tracts and

fibrotic scars. Therefore, treatment requires a combined approach in order to be successful.

First, inflammatory activity needs to be improved. This can be achieved by systemic anti-

inflammatory or immunosuppressive treatment. However, (non-inflammatory) sinus tracts and

fibrotic scars will remain present after systemic therapy. The only way to permanently remove

these sinus tracts and fibrotic tissue is by means of surgery.

Currently, the classic deroofing technique and wide excision are regarded as the preferred

surgical methods for treating HS Hurley stage I/II and stage II/III respectively.3,4 However,

Hurley stage II/III disease remains a surgical challenge and the surgical treatment has dual

aspects. On the one hand, the goal of surgery is to achieve complete removal of lesional tissue.

On the other hand, it is important to spare as much healthy tissue as possible to prevent the

formation of serious contractures and to promote wound healing. The latter is not achieved

with wide excision. To meet both goals to a maximum we have developed a surgical technique

for severe HS where the advantages of both wide excision and the deroofing technique are

combined: the Skin-Tissue-sparing Excision with Electrosurgical Peeling (STEEP) procedure.

100

TEcHNIQUEThe STEEP procedure is performed under general anesthesia. The procedure starts with

palpation of the affected area to localize inflammatory nodules and fibrosis. Visible sinus

tracts are then sondaged with a probe to investigate their extensiveness. The sinus roof is

subsequently electrosurgically incised with a wire loop tip coupled to an Erbotoom (Erbe

USA Inc. Surgical Systems). This method is similar to the deroofing technique as described

previously for Hurley stage I/II disease.(3,4) Subsequently all lesional tissue, including fibrosis

that is identified by palpation, is removed from the incision on to the deeper skin layers by

successive tangential electrosurgical transsections (figure 1). The epithelialized sinus floors

and subcutaneous fat are left intact where possible. This procedure of incising sinuses and

tangential peeling off affected tissue is continued until the whole area is clear of lesional

tissue and fibrosis. Finally, the wound margins are meticulously checked with a probe for

the presence and removal of any residual sinus tracts. Hemostasis is achieved by using the

coagulation mode of the Erbotoom. The wound margins (i.e. healthy tissue) are injected with

triamcinolonacetonide 10-20mg and bupivacaine 0.5%(10ml) to prevent hypergranulation.

Wounds are left open to heal by secondary intention. Post-operative wound care consists

of twice daily irrigation followed by alginate and silicone dressings. Pain is managed with

acetaminophen, non-steroidal anti-inflammatory drugs or, in severe cases, opiates. Generally,

patients can leave the hospital on the day of surgery.

Figure 2 illustrates an example of the satisfying cosmetic results we achieve with the STEEP

procedure. This 46-year old woman with severe therapy resistant HS in the genital area was

initially treated with intravenous infliximab for six months. After five infusions, inflammatory

activity had improved and the STEEP procedure was then successfully performed in two

separate sessions. Currently (i.e. three years later), the disease is still in remission. Additionally,

her quality of life has significantly improved, as reflected in a reduction of her Dermatology Life

Quality Index (DLQI) from 28 points (maximum: 30) at the beginning of infliximab treatment

to 3 points at eight months after the final STEEP procedure.

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Figure 1. Wide excision (a): red dotted line represents the cutting surface. Healthy tissue is removed and resection reaches

into the subcutaneous fat. STEEP-procedure (b): inflammatory nodules, sinus tracts and scar tissue are localized by a

probe or with palpation. Affected tissue is then peeled off layer by layer by means of multiple tangential transsections (red

dashed lines). The epithelial lining is spared in non-inflammatory sinus tracts but is totally excised in inflammatory sinus

tracts (blue dashed lines). The procedure is repeated until a plane has been obtained that is free of lesional tissue. The

result is that the final defect is smaller compared to wide excision.

Figure 2. Right groin before treatment with the STEEP procedure. Sondage with a tissue forceps demonstrates the depth

of the sinus tract (a). The right groin 24 weeks after the STEEP procedure (b).

Epidermis

Subcutaneous fat

Dermis

Sinus tract (non-inflammatory) Inflammatory nodule

(a) (b)

(a) (b)

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DIScUSSIoNTreatment of HS is a challenge for both physicians and patients due to its complex and largely

unknown pathogenesis. It is generally accepted that in order to achieve satisfying results in

severe cases (Hurley stage II/III disease), a dual therapeutic approach is required.5 Usually, the

first step is inhibition of inflammatory activity with anti-inflammatory or immunosuppressive

agents, including infliximab.5,6 However, systemic treatment will not restore the skin’s

original architecture, meaning that epithelialized cysts and sinus tracts will remain present

in the affected skin once the inflammation has been treated. This may facilitate access for

(commensal) bacteria, leading to repetitive inflammation and further extension of the disease,

with ever-increasing architectural destruction.7 This vicious circle can only be interrupted by

surgical removal of these residual lesions.

The STEEP procedure is a promising tissue-saving surgical technique for HS Hurley stage II/III.

Tissue-saving surgical techniques are importance to HS for two main reasons: (i), HS especially

occurs in the body folds, which are areas prone to the formation of contractures after surgery

and (ii) large interconnected skin areas are frequently involved, making it even more important

to reduce the size of the already large surgical defects to a minimum. A suitable tissue-saving

surgical technique for Hurley stage I or limited stage II disease is the deroofing technique.3,4

However, in case of extensive Hurley stage II/III disease dominated by fibrotic tissue, the

deroofing technique is ineffective since fibrosis is not removed. Removal of fibrotic tissue is

important because it may contain skin appendages that serve as a source for recurrence and

also prevent adequate wound contraction and subsequent healing. In addition, the deroofing

technique is too time-consuming in severe HS. Surgical intervention by means of wide excision

is therefore often considered as the most effective treatment in these cases.8 However, the

STEEP procedure has several advantages over both wide excision and the deroofing technique

in severe HS. First, wide excisions always reach into the healthy deep subcutaneous fat, while

the STEEP procedure with its successive tangential transsections leaves the epithelialized

bottoms of the sinus tracts and a large extent of the subcutaneous fat intact, leading to more

superficial and smaller defects (fig 2). This results in relatively shorter healing times and fewer

complications, such as contracture formation. Furthermore, recurrence rates around the

operated area are reduced to a minimum since at the end of the STEEP procedure residual

affected tissue is identified and removed by sondaging the final wound margins with a probe

and extensive palpation. Tissue-sparing surgery in HS can also be accomplished with the use

of a CO2 laser, as previously demonstrated.9-13 The main advantage of CO2 laser incision is that

proper hemostasis is achieved allowing adequate visualization of remaining lesional tissue.

During the STEEP procedure prompt cauterization of bleeding vessels can be easily achieved

103

as well by switching between the surgery and electrocautery mode of the electrosurgical unit

using a foot pedal. For the performance of multiple transversal sections as we describe for our

surgical technique, electrosurgery has some important advantages over CO2 laser, namely:

(i) the depth of vertical incisions with transversal electrosection is more easily controlled and

adjusted by the surgeon. This leaves the epithelialized sinus bottom intact and warrants deep

excision of fibrotic and inflammatory tissue at the same time while a CO2 laser removes a

continuous horizontal plane of one depth, making it less precise and less tissue-sparing; (ii)

laser treatment is more expensive in terms of purchasing the device, the need for a special

room to perform the treatment and safety notices; and (iii) a basically trained dermatosurgeon

can perform electrosurgery, while laser treatment requires more experience and skills.

In our clinic, we have performed the STEEP procedure under general anesthesia in 156

patients with Hurley stage II/III disease between 2004 and 2013. The feedback from the

patients is generally very positive. Patients with extensive disease at multiple locations were

usually operated in several sessions. The wounds are allowed to heal by secondary intention

since in our experience, and that of others, it is time-efficient and leads to good cosmetic and

functional results.14,15 Furthermore, it allows prolonged wound drainage, diminishing the risk of

wound infection.14

In conclusion, we consider the STEEP procedure with electrosurgery superior over wide

resections and deroofing in Hurley stage II/III disease for several reasons: (i) recurrence rates

are low as it specifically aims at complete removal of lesional and fibrotic tissue; (ii) it saves

healthy tissue to a maximum which leads to rapid healing, satisfying cosmetic results and

prevention of contractures; (iii) healing time is further improved by allowing re-epithelization

of the defects from the intact epitheliazed sinus floors and dermal tissue where possible

rather than from subcutaneous fat; and (iv) in contrast to laser surgery the procedure can be

performed by basically trained dermatologic surgeons.

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