Abstract: Hidradenitis suppurativa is characterized by chronic infection of the apocrine sweat glands. Radical excision of affected areas yields the best long-term results when conservative treatment modalities fail. Larger defects from excision are frequently reconstructed using skin grafts or are allowed to heal by secondary intention. Although radical excision yields the best results in terms of disease control, the defects remaining after wound healing can be disfiguring. In the present case, previously excised and grafted inguinoperineal defects were repaired utilizing medial thigh flaps.

       Hidradenitis suppurativa (HS) is an uncommon disease involving chronic infection of the apocrine sweat glands. When conservative treatment fails, radical surgical excision yields the best rate of cure. The areas of involvement can include the axilla, buttocks, groin, perineum, and perianal area.
       Wound closure after excision most commonly occurs via primary closure in small wounds and via secondary intention or skin grafting in large wounds. The defects that remain can be difficult to repair particularly in areas traditionally difficult to reconstruct. The present case involves the repair of disfigurement from serial excisions in the perineum utilizing medial thigh flaps.

Case Report

       A healthy, 37-year-old woman was referred for assessment of perineal-thigh crease deformities. The patient had a long history of HS in the perineum and had 2 excisions in the year prior to presentation. The first excision had been closed via a layered technique that subsequently broke down. A secondary procedure with skin grafting was later performed, which apparently cleared the disease. The patient was dissatisfied with the large contour defects left by the secondary procedure (Figure 1A and 1B).

Figure 2

Figure 1B

Figure 1A

       Physical examination revealed bilateral inguinoperineal defects with no evidence of recurrent disease. The patient requested surgical treatment. Excision of the skin grafts was followed by advancement of medial thigh flaps into the defects. No residual disease was noted at surgery or in the surgical specimen pathology. Follow-up at 2 months showed a good aesthetic outcome (Figure 2).

Discussion

       Although first reported in 1839 by Velpeau, HS is incompletely understood.¹ It manifests by chronic infection of the apocrine sweat glands leading to chronic abscesses and sinus tracts with fibrosis. The disease is more commonly seen in women following puberty presumably related to increased apocrine gland activity. Although the condition has been seen in all races, those of African descent seem more commonly afflicted.² Medical management comprises improved hygiene, antiseptics, and topical as well as systemic antibiotics. Hormonal therapy and topical retinoids and steroids have been used with variable success in halting disease progression. Disease that persists or progresses despite optimal medical treatment frequently is referred for surgical management.
       For disease control, radical excision of affected areas yields the best long-term results but is commonly associated with post-operative deformity. A recent review offered a treatment algorithm designed to help determine the method of wound closure after excision.³ The discussion of wound management in this review, as well as the literature in general, has focused on limiting the rate of re-operation without much attention to limiting disfigurement.
       Less extensive surgery has been advocated for gluteal and perineal disease, thereby decreasing the deformity.⁴ Perineal disease, however, may be more commonly associated with recurrence.⁵ Unfortunately, the time course over which recurrence manifests is not well documented. Most authors have recommended resection with skin grafting as the reconstructive procedure of choice. Simple excision and closure may lead to an unacceptably high rate (54%) of re-operation in axillary disease.⁶ There do not seem to be enough published reports to extend this conclusion to perineal disease.
       There has been little attention to reconstruction of the frequently disfiguring wounds left by excision in this disease. This may be due to a concern of later recurrence. For this reason, the point at which reconstruction should be considered is open to debate. When patients desire reconstruction and the disease appears to be under control, discussion of reconstruction may be appropriate in cases of severe deformities in which correction seems straightforward. A medial thigh lift for treating inguinoperineal disease may be utilized with good results.

Conclusion

       Extensive HS can be associated with large disfiguring wounds. In the present case, unsightly defects were the result of excision and skin grafting. In intermediate term follow-up, recurrent disease was not noted, and the patient strongly desired reconstruction. A medial thigh lift was used with a good result in the short term.
       Considering the high recurrence rate in perineal HS, it may be advisable to perform initial excision and skin grafting. Once post-operative evaluation indicates clearance and wound sepsis is controlled, definitive reconstruction (if desired) can be considered. Certainly, a discussion of the potential for subsequent disease recurrence should precede reconstruction in this type of case.