Recurrencia de HS luego de cirugía extensa.

Published in Dermatology

Journal Scan / Research · September 24, 2018

Recurrences of Hidradenitis Suppurativa After Radical Surgery

Dermatologic Surgery

TAKE-HOME MESSAGE

• This study characterized the recurrences of hidradenitis suppurativa (HS) and associated risk factors in patients who underwent HS excision. At 1-year post excision for HS, 54.2% of 48 patients suffered recurrence. On average, recurrence was 1.7 years after surgery (range, 3 weeks to 5 years). Most recurrences were close to surgical sites (<1 cm margins). Patients who had surgery under tumescent anesthesia had more recurrences compared with those who had general anesthesia (40.6% vs 28.6%). Alcohol consumption (averaging 3.4 glasses per week) was associated with relapse, while body mass index and smoking were not.

• About of half of patients who underwent wide excision for hidradenitis suppurativa had recurrences, most often near surgical sites. Local anesthesia may be associated with higher recurrence risk. 

– InYoung Kim, MD, PhD

 Dermatology

Written by

 

 

Paul G Hazen MD

Published results of surgery for hidradenitis suppurativa generally assess the incidence of recurrence following treatment. This publication attempts to define and then evaluate the success of wide local excision, to give a more refined definition to the concept of recurrence, and to evaluate factors that might contribute to recurrence risk. The authors defined wide local excision to be a 1- to 2-cm margin beyond clinically involved skin, with excision to the level of irritation-free fatty tissue. They further defined "recurrence" to be either of "local recurrence" or "distant recurrence." Local recurrence was identifiable as one of three potential patterns: 1) Within the surgical field; 2) <1 cm from the surgical border; or 3) >1 cm from the surgical border. "Distant recurrences" were defined as inflammatory lesions following surgery in never-affected areas. Recurrence rates were not limited to any predefined postoperative period.

The study evaluated 48 patients, 29 women (60.4%) and 19 males, all with Hurley stage III disease who underwent wide surgical excision. A total of 91 areas over a period of 5 years were treated. The inguinal and axillary areas were the most common surgical sites (40 and 39 procedures, respectively). General anesthesia combined with tumescent anesthesia was used for 59 procedures, tumescent anesthesia alone in 28 patients, and local anesthesia only in 4 patients. A total of 47 (52%) surgical events healed by secondary intention, with 44 sites (48%) healing with meshed skin grafts.

Recurrences were noted within the surgical field in 14% of patients and within or close to the surgical field in 30 patients (33.3%), occurring on average 1.7 years after surgery (range, 3 weeks to 5 years). More local recurrences were noted in the inguinal area (45% local recurrence rate) than the axilla (20.5% recurrences). Overall, 14 patients (46.7%) showed "recurrent" disease in the same anatomic area, but >1 cm outside the surgical site. Local recurrences were nodules or abscesses, without sinus tract or hidradenitis suppurativa–related scarring. There were fewer recurrences in patients treated with general rather than local anesthesia.

Smoking history, body mass index, family history, gender, and number of operations were not statistically significant for risk of recurrence. Alcohol consumption appeared to be associated with a risk of local recurrence but not distant recurrences.

Recurrence after hidradenitis suppurativa surgery has generally been considered to be the appearance of new lesions within or abutting the surgical site. The authors attempt to expand the definition to include nearby areas. Uncertain is whether the inclusion of "distant recurrence" is more likely to be new disease. Additional observations were that local recurrences were noted to be nodules or abscesses rather than sinus tracts or hidradenitis suppurativa scars and that inguinal site surgery was at higher risk for recurrence than axillary or other areas. Patient satisfaction rates were not quantified, but were noted to be significant. Risk of recurrent disease continues to be a concern in the surgical management of hidradenitis suppurativa.

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Abstract

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic debilitating skin disease in inverse body areas. Wide excision is recommended in Hurley Stages II to III, but the rate and symptoms of recurrences in long-term follow-up remain unclear.

OBJECTIVE

To analyze the allocation of recurrences regarding the operative field, the onset and quality of HS symptoms as well as factors associated with recurrences in long-term follow-up.

MATERIAL AND METHODS

Forty-eight patients with Hurley Stage III disease who had undergone 91 wide excisions from 2010 to 2015 were clinically examined regarding postoperative complications and allocation and quality of recurrences. To determine the risk of recurrence, possible surgery, and lifestyle-related associated factors were investigated.

RESULTS

Postoperative recurrences of HS were seen in 54.2%. Most recurrences (inflamed nodules) were detected in a <1-cm margin around the operative field (18.7%). Surgery under tumescence local anesthesia showed symptoms in 40.6% compared with 28.6% under general anesthesia. Increased alcohol consumption (p = .027) but not body mass index (p = .11) or smoking behavior (p = .45) had significant effect on relapse of HS.

CONCLUSION

Caution must be given especially in surgery with local anesthesia only. Half of patients with HS showed long-term follow-up signs of recurrence after wide excision, most frequently nearby the operation field.