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University of Groningen
Hidradenitis suppurativaDickinson-Blok, Janine Louise
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Publication date:2015
Link to publication in University of Groningen/UMCG research database
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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Download date: 25-01-2020
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.
101
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)
102
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.
104
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