Transcript Chronic Ulcerative Colitis Assessment and Surgical Management

Hidradenitis Suppurativum
Nigel A. Scott MD FRCS
Royal Preston Hospital
Hidradenitis Suppurativum
Greek- hidros=sweat & aden=glands
“Painful, inflamed lesions in the axillae, groin, and other
parts of the body that contain apocrine glands”
“…..painful eruptions and malodorous discharge”
Quality of Life and Hidradenitis
J.M. Von Der Werth, G.B.E. Jemec (2001)
Morbidity in patients with hidradenitis suppurativa
British Journal of Dermatology 144 (4), 809–813.
Hidradenitis Suppurativum
“Apocrine” Sweat Glands
• develop during mid puberty
• sweat contains fatty materials that are broken down by
bacteria – main cause of sweat odour
• emotional stress increases production of sweat
Hidradenitis Suppurativum
Apocrine
Hidradenitis Suppurativum
[not Apocrine]
Hidradenitis Suppurativum
• occlusion of the hair follicle
(rather than the apocrine
gland) due to a defect in
terminal follicular epithelium
Hidradenitis Suppurativum
1. occlusion of the hair follicle
(rather than the apocrine gland)
due to a defect in terminal
follicular epithelium
2. bacteria invade the apocrine
system via the hair follicles,
become trapped beneath the
keratinous plugs, and multiply
rapidly in the apocrine sweat
Hidradenitis Suppurativum
3. glands rupture and spread the infection
extending the tissue destruction and skin
damage
Hidradenitis Suppurativum
3. glands rupture and spread the infection
extending the tissue destruction and skin
damage
4. bacterial superinfection with streptococci,
staphylococci, and coliforms
- BUT cultures from lesions are frequently
sterile and antibiotics are not curative
Hidradenitis Suppurativum
• chronic acneiform
infection of the cutaneous
apocrine glands
• involves adjacent
subcutaneous tissue and
fascia
•
hallmark - is sinus tracts
(which can become
draining fistulas) in the
apocrine gland body
areas.
Hidradenitis Suppurativum
Apocrine Gland distribution
• axillae
• periareolar, intermammary
• pubic area,
• infraumbilical midline,
• gluteal folds,
• genitofemoral areas
• perianal region.
Hidradenitis Suppurativum
Stage 3 Hidradenitis Suppurativum
Stage 1: Single or multiple
abscesses form, without sinus
tracts and cicatrization
Stage 2: Recurrent abscesses
with tract formation and
cicatrisation - single or multiple
widely separated lesions.
Stage 3: Diffuse or neardiffuse involvement or multiple
interconnected tracts and
abscesses are observed
across the entire area
Hidradenitis
2-4% population
4F:1M
Gender and disease location
Area(s) of
involvement
Male (n = 15) Female (n = 42) P value
Axilla
2 (13%)
37 (88%)
<.0001
Unilateral 1 (50)
19 (51)
NS
Bilateral 1 (50)
18 (49)
Inguinoperineal
13 (87%)
Unilateral 1 (8)
Bilateral 12 (92)
Axilla and
inguinoperineal
1 (7)
5 (12)
<.0001
4 (80)
.0131
1 (20)
3 (8)
NS
Kagan et al. Surgical treatment of hidradenitis suppurativa: A 10-year experience
Surgery 2005:138(4);734-741
Hidradenitis – medical options
• topical clindamycin
• hormonal cyproterone acetate;
ethinyloestradiol
• retinoids
• infliximab
CO2 Laser
J Amer Acad Derm 2002:47:280-285
Hidradenitis –surgical options
• drainage of sepsis – 100%
recurrence
• laying open of tracks
• wide local excision +/- skin grafts
“The surgical option of choice for late stage
HS is wide local excision with healing by
secondary intention”
Surgical treatment of hidradenitis suppurativa
Br J Surg 1992; 79: 863-6.
Hidradenitis –surgical options
Axillae – wide local excision & secondary healing
Hidradenitis –surgical options
Genitofemoral
– wide local excision & secondary healing
Genitofemoral
– wide local excision & secondary healing
Genitofemoral
– wide local excision & secondary healing
Genitofemoral
– wide local excision &
secondary healing
Genitofemoral
– wide local excision &
secondary healing
Perianal Hidradenitis
Hidradenitis –surgical options
Perianal Disease – differential diagnosis
•Crohns disease
•Cryptoglandular sepsis
•pilonidal disease
•tuberculosis,
actinomycosis etc
Anal Canal &
Hidradenitis
• the distal two thirds of the
skin of the anatomic anal
canal contains hair follicles
with sebaeceous and
apocrine glands
•hidradenitis supprativum
rarely involves the anal
canal
•if it does it tracks
subcutaneously and not
across the sphincter
•it never tracks above the
dentate line
Anal Canal & Hidradenitis
Crohns
Cryptoglandular
Hidradenitis
Hidradenitis –surgical options
Perianal Disease – differential diagnosis
Perianal Hidradenitis
• drainage of sepsis
• laying open of tracks
• wide local excision +/- skin grafts
• [? colostomy]
Perianal Hidradenitis
– wide local excision & secondary healing
Perianal Hidradenitis
– wide local excision & secondary healing
Perianal Hidradenitis
– wide local excision & secondary healing
Kagan et al. Surgical treatment of hidradenitis suppurativa: A 10-year
experience Surgery 2005:138(4);734-741
Axilla
Perineum
Inguinal
Kagan et al. Surgical treatment of hidradenitis suppurativa: A 10-year
experience Surgery 2005:138(4);734-741
Hidradenitis – surgical outcomes
Ritz et al Extent of surgery and recurrence rate of hidradenitis
suppurativa Int J Colorectal Dis 1998;13:164-168.
• 31 patients 6F:23M
• mean age 31yrs
• surgery
• 6 abscess drained
•14 limited excision, 2 suture
•11 wide local excision
Ritz et al Extent of surgery and recurrence rate of hidradenitis
suppurativa Int J Colorectal Dis 1998;13:164-168.
Drainage
Local Excision & Suture
WLE
Hidradenitis Suppurativum
Summary
• common cause of serious morbidity 1-4%; 4F:1M
• occlusion of the hair follicle (rather than the apocrine gland) due to a
defect in terminal follicular epithelium
• axilla/ inguinogenital, perianal
• Stage 3: Diffuse or near- diffuse involvement or multiple interconnected
tracts and abscesses are observed across the entire area
• medical - topical clindamycin, oral contraceptive
• perianal – differential diagnosis
• wide local excision best results with or without mesh skin graft
The DoH said: "The department has accepted the need for change and
the revised approach will now be tested with junior doctors, selectors,
deanery recruitment teams and employers."