Medical treatments have relied on suppressing the inflammation of the disease, often through the use of antibiotics. Note that the antibiotics are not thought to work by killing germs, but rather by controlling the inflammation. Other anti-inflammatory medications can also be very helpful, leading to prevention of HS flares, and healing of affected areas. Newer medications such as Humira (adalimumab), or Remicade (infliximab) have also been shown to be very helpful. Much investigation is underway to further test new similar therapies for this condition.
Surgical treatments have been reserved for patients in need of care unable to be obtained with medications. “Wide” excision (cutting out the affected areas) has long been recommended, although there is significant risk of recurrence. Other treatments including spot removal, unroofing, injections with freezing agents, and treatment with lasers have all been investigated.
OUR TREATMENT FOR PERSISTENT OR TUNNEL AREAS OF HS
For a number of years we have been using a technique of “carbon dioxide laser excision and marsupialization” to treat persistent individual lesions, as well as intercommunicating tunnels. We have found that removal using a carbon dioxide laser has allowed the surgeon to identify and remove sinus tracts and extensions that would not otherwise be visible. As such, complete removal has been more successful than with other methods. Indeed we previously reported our results wherein there were only 2 recurrences in 185 areas treated. Follow-up in our patients averaged over 4 years and ranged from 1-17 years. Since our original publication, many additional patients have been treated, with a total of 332 areas treated and 6 recurrences (1.8% incidence) as of July, 2011.
The technique we have found to be effective is as follows. Patients can be treated in the office setting. A topical anesthetic is applied to reduce surface discomfort, followed by a local anesthetic injection to produce more complete comfort to the affected area. General anesthetic is not normally needed. The CO2 laser is then used to cut around and under any areas of tunneling, scars or inflammation. Generally, the depth is in the deep dermal layer (where the hair follicles reside), so that it is not normally necessary to enter muscles. By examining the interior of the surgical site, it is possible to discover hidden tunnels of affected skin – the presumed reason why so many other approaches fail. All affected tissue is thereby removed, and the laser then used to produce a smooth interior wound. Total time for the procedure is normally 2 ½ -3 hours. Wound healing takes place naturally, initially filling in the depth of the area, and subsequently healing the surface skin. Because no muscle is disturbed, healing is generally comfortable, with only a surface dressing and daily bandage change. Healing is usually complete after 8-10 weeks. Qualities of healing have been acceptable to excellent, and no patient has required scar revision.
Complications from the CO2 laser approach have generally been rare. The main inconveniences are: 1) that there is a limitation on the size of the area which may be treated at one session and 2) that healing will be gradual, normally over a period of weeks. Treating too large an area at one session may require quantities of local anesthetic which could be unsafe. Also, since the size of the area to be treated will influence the convenience of the patient post-operatively, larger areas will be more challenging for care. For both reasons, a substantial area will occasionally be completed in two sessions. Similarly, the individual with multiple areas will also often require multiple sessions. Again, the advantages of performing the surgery in the outpatient setting, with local anesthesia, with no hospital stay, and with good comfort postoperatively have made this approach an attractive option to many patients.
Other complications must also be considered. Bleeding, discomfort, delayed healing, infection, scarring and recurrence are all possible but are uncommon.
TOTAL HS MANAGEMENT
One of the frustrations of HS is that new areas may appear, even if old areas remain clear. For many patients, medical efforts to prevent new lesions should be coupled with resolution of old areas. A key focus of our research is the question of how to prevent the ongoing nature of the process.