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Introduction
CHAPTER 54 Hidradenitis
Suppurativa
K. R. van Straalen A. R. J. V. Vossen E. P. Prens H. H. van der Zee
SUMMARY
Local cure of HS can be accomplished with elective surgical procedures.
Surgery is indicated throughout all stages of hidradenitis suppurativa, with the
exception of the mildest forms.
Surgical interventions for HS include intralesional injection of triamcinolone,
incision and drainage, deroofing, and excisional surgery (including CO2 laser).
Beginner Tips
Cryoanesthesia with liquid nitrogen or a refrigerating spray is useful, as the inflamed
area is difficult to anesthetize using injectable anesthetics.
Cryoanesthesia should be performed over the full length of the planned incision or
injection site.
Acute surgical interventions, that is, intralesional injection of triamcinolone and
incision and drainage, can be performed to quickly relieve symptoms of inflammatory nodules and tense abscesses.
Expert Tips
Secondary intention healing is ideal as it obviates the risk of entrapping diseased skin
leading to recurrence.
The extent of sinus tract formation can only be established intraoperatively, and the
affected area is often considerably larger than expected based on the preoperative assessment.
The addition of color Doppler ultrasound may add relevant information prior to
surgery.
Donโt Forget!
Photodynamic therapy (PDT) may be useful in the treatment of HS through selective,
cytotoxic, and immunomodulatory effects.
Pitfalls and Cautions
Patients with HS in the perianal or perineal area, especially male patients and those
with concomitant intestinal bowel disease (IBD), are at risk of developing fistulas penetrating through the anal sphincter complex or communicating with the rectum. The presence of trans- or intersphincteric sinuses or fistulas should preferably be assessed by endorectal MRI or a fistulogram preoperatively.
Patient Education Points
Patients should appreciate that HS is a chronic disease, and that any intervention runs
the risk of potentially serious side effects.
To ensure the best patient outcomes, surgeons should select the appropriate surgical
technique based upon operator experience and the individual needs of the patient.
Patients should be highly motivated prior to initiating HS surgery, as recovery times
may be protracted and require significant wound care and physical therapy.
Billing Pearls
Hidradenitis excision may be coded with the 11450-11471 series codes.
CHAPTER 54 Hidradenitis