Surgical Treatment of Sinuses by Deroofing in Hidradenitis Suppurativa

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Hidradenitis suppurativa (HS, acne inversa), is a recurrent, chronic, inflammatory disease, usually presenting after puberty with painful, deep-seated inflamed lesions primarily affecting the apocrine gland-bearing areas of the body. Recent studies suggest a prevalence of approximately 1%. HS has a great psychosocial and economical effect on the life in addition to the physical problem.Clinically, it presents with tender subcutaneous nodules that can rupture spontaneously or coalesce into deep, painful abscesses. This may eventually result in fibrosis and formation of sinuses.1HS is a difficult-to-treat disease in which the choice of treatment depends on severity, course of the disease, and preferences of the patient. For describing HS severity, staging according to Hurley can be used (Figures 1-3).2Patients with mild HS (Hurley I) may benefit from topical or systemic treatment, sometimes combined with surgery (incision with drainage), but if sinuses have formed, response to topical and oral medication is poor, and surgical treatment is necessary.1 In patients with Hurley stage III, a combination of oral medication and more-extensive surgery (entire block resection) is often needed. Results of conventional surgical methods may be disappointing; incision and drainage have high recurrence rate, whereas block excision takes prolonged wound healing.In a subgroup of people with HS with superficial sinuses (Hurley II), no or mild fibrosis, and recurrent lesions at the same locations, we use the deroofing method according to Bos,3 a modification of the technique described by Brown and colleagues.4 During the procedure the sinus “roof” is removed electrosurgically, and side passages are explored and treated, leaving the sinus floor untouched. Wound healing is by secondary intention. With this simple tissue-saving procedure, re-epithelialization is rapid, and local recurrences are rare.TechniqueOur patients were treated under local infiltration anesthesia using Xylocaine 2% with adrenaline 1:200,000. Field block anesthesia might be insufficient if the center of the lesion is fibrotic or if there is inflammatory infiltrate. Therefore, we start infiltration anesthesia at the border and work our way up to the center.Openings are explored with a probe to search for sinuses, cysts, and epithelialized side passages. Because it is important not to miss side passages, we check the sinuses carefully (Figure 4A–C).When the sinus cavity is found, we remove the sinus roof using electrosurgical dissection with a wire loop tip coupled to an Erbotoom (Erbe USA Inc. Surgical Systems), which follows the probe along the sinus until the end of the tract is reached, leaving the epithelial bottom of the sinus intact (Figure 5). Residual tissue fragments on the margins are also removed to prevent premature re-epithelialization.Excision of the roof with electrosurgical loop instead of incision with a knife has two advantages. First, prompt hemostasis can be achieved, which makes further coagulation unnecessary. This is important because the epithelial lining of the sinus floor, which serves as a source for re-epithelialization, has to be kept intact. Second, removing the overlying skin over the probe and subsequent retraction of the surrounding tissue will cause the tract to open in a V shape. The V shape prevents premature closure when the wound re-epithelializes from the sides.Postoperative care consists of alginate and silicone dressings. The dressings are changed daily after irrigating the wounds under the shower.ResultsOur experience with this technique, especially when used in the subgroup of individuals with HS with superficial sinuses and no or little fibrosis is good.

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