CASE STUDY

Hidradenitis suppurativa (HS) is a painful and debilitating, chronic inflammatory disease affecting the skin bearing apocrine glands. HS results in abscesses, nodules, interconnected sinus tracts, and fibrous scarring of the skin in the axilla, groin, perineum, and breasts. It is estimated that HS affects between 1% and 4% of the population, occurs more commonly in women than in men at a ratio of roughly 3:1 (Jemec, 2012), and has a higher prevalence in African Americans (Falola et al., 2016). Because of the pain and disfigurement of HS, this can be a debilitating disease, negatively affecting patients' mobility, relationships, work productivity, and quality of life (Falola et al., 2016). There are limited curative options for HS; however, depending on the severity of the disease, there are treatment options available. This case study discusses the pathophysiology of the disease, severity staging, treatment options, and a recent patient case.

The pathophysiology of HS is unclear and thus there is no simple cure for this disease. According to Romanowski et al. (2017), "the pathophysiology of HS is poorly understood, but it is generally believed that obstruction of apocrine pores results in glandular dilation and bacterial superinfection with subsequent gland rupture that disseminates infection." Although the cause of pore obstruction with resultant rupture and infection is not fully known, there are multiple risk factors that may predispose individuals to this condition. Smoking and obesity are the two leading risk factors for developing hidradenitis, and they both directly correlate with the severity of the disease (Jemec, 2012). All patients suffering from HS should be counseled on weight reduction and smoking cessation.

Hidradenitis usually follows a pattern of relapse and remission, with flares lasting 7-10 days. Jemec 2012 points out, "Recent investigations suggest that the interleukin-12-interleukin-23 pathway and tumor necrosis factor [alpha] (TNF-[alpha]) are involved in the pathogenesis of hidradenitis suppurativa, supporting the proposition that it is an immune or inflammatory disorder." Long-term antibiotic therapy and immunosuppression are sometimes used in less severe cases of HS because of the immune-mediated and inflammatory nature of the disease (Jemec, 2012). Treatment selection is usually guided by the severity of disease. Several classification systems have been developed to attempt to correlate clinical features with prognostic significance. The Hurley clinical grading system is the most commonly used severity scale (Falola et al., 2016).

The Hurley clinical grading system consists of three stages of the disease. Stage I is described as mild disease with abscess formation without sinus tracts or scarring. Stage II is described as moderate disease with single or multiple abscesses covering a large area with associated sinus tracts and scarring. Stage III is the most severe form of the disease, described as numerous inflamed nodules, interconnected sinus tracts, and diffuse scarring. Treatment options for Stage I disease include meticulous hygiene of the affected area, topical and/or oral antibiotics, immunosuppression, and antiandrogen therapy. Stage II disease can also be treated with these therapies, but may require more aggressive care (Chen & Friedman, 2011). Surgical intervention may become necessary with progressing disease severity.

Stages II and III disease may require incision and drainage, local excision of tissue, surgical deroofing of skin tracts, or even wide excision of all involved hair bearing skin (Falola et al., 2016). With regard to wide surgical excision, Chen and Friedman (2011) state, "Not only does it definitively treat the disease process, but also can relieve problematic wound contractures that limit function, as well as removing the risk of future conversion to squamous cell carcinoma." Reconstruction of the excised area can be performed with many different techniques including primary closure, secondary wound healing, local or perforator flaps, and skin grafts (Chen & Friedman, 2011).

R.B. is a 23-year-old African American woman who had previously undergone excision of tissue in the right axilla for Stage II hidradenitis. Postexcision, wound vacuum-assisted closure (VAC) therapy was implemented to manage drainage and promote granulation tissue formation. The wound VAC was discontinued prior to discharge, and the patient was sent home with daily wound care instructions and home health support. General surgery then referred the patient to plastic surgery for wound closure with skin grafting. Evaluation in the plastic surgery clinic revealed a 12 cm-by-7 cm full-thickness wound. The wound was deemed appropriate for debridement and placement of autologous split-thickness skin graft (STSG).

Six weeks after original excision took place, the patient was taken to the operating room for debridement and skin grafting. Postoperatively, VAC therapy was again used to secure STSG and manage postoperative exudate. She was later discharged home with instructions for daily wound care with a nonadherent silicone dressing that promotes epithelialization and is atraumatic to the wound bed. Weekly follows-up revealed good wound healing with minor complications, such as the formation of hypergranulation within the grafted tissue. Hypergranulation is a mound of tissue that extends above the wound bed and prevents epithelialization. Silver nitrate was applied to these areas to chemically "burn" the tissue flat and allow epithelial cells to migrate from the edges of the wound bed. Another minor complication was the development of a heavy green, foul smelling pseudomonal exudate, which is very common in this type of chronic open wound. This was managed with 7 days of quarter strength Dakin's solution soaks. Otherwise, R.B. healed well and had no other complaints of pain or complications. Within the upcoming weeks, she will begin physical therapy for range of motion of upper body.

When performing wide excision with planned skin grafting, Chen and Friedman (2011) recommend applying a wound VAC to the exposed adipose tissue for 1 week, then bringing patients back to the operating room for STSG placement. The wound VAC is then reapplied for an additional week to the STSG. It is felt this promotes angiogenesis of the wound bed and then prevents grafts from becoming dislodged from shearing forces associated with areas like the axilla and perineum (Chen & Friedman, 2011). R.B.'s treatment course did not follow the specific sequence of events outlined by Chen and Friedman (2011), but the treatment strategies are similar and this patient has healed well.

Falola et al. (2016) explains, "For patients with large and/or contaminated HS defects, delayed reconstruction with interval use of internal vacuum-assisted therapy, before definitive closure has shown improved outcomes when compared with single-stage repair". Bacterial colonization and wound infection inhibit successful healing, and as such, premature closure of excision of tissue in the axilla and perineum can lead to wound dehiscence and recurrence of disease (Falola et al., 2016). R.B. is an example of an ideal patient to manage with VAC therapy and delayed reconstruction. Although there are studies and reports of success with many different management options of HS, more research is needed. Hidradenitis suppurativa is a complex disease that requires large-scale randomized controlled trials to define optimal treatment strategies for patients' suffering from this painful condition.

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