Is surgical intervention with flap surgery the only option for recurrence in hidradenitis suppurativa?

Surgical Options for Recurrence in Hidradenitis Suppurativa

No, surgical intervention with flap surgery is not the only option for recurrence in hidradenitis suppurativa, though it offers among the lowest recurrence rates for extensive disease. Multiple surgical and non-surgical approaches can be used for recurrent disease, with the choice depending on disease severity, location, and extent.

Surgical Treatment Options for Recurrent Disease

Wide Excision Options

• Radical wide excision: Offers lower recurrence rates (2.5-27%) compared to limited excision (42.8%) or drainage procedures (100%) 1
• Reconstruction methods after excision:
  • Secondary intention healing: Good to excellent results in 66.7% of cases 1
  • Primary closure: High recurrence rate (69.9%) 2
  • Split-thickness skin grafts: Very low recurrence rates 2
  • Flap reconstruction: Lowest recurrence rates among closure techniques 2, 3

Less Invasive Surgical Options

• Deroofing procedure: 83% showed no recurrence during median follow-up of 34 months 1
• STEEP (Skin-Tissue-Saving Excision with Electrosurgical Peeling): 29.2% recurrence rate over 43 months 1
• CO2 laser excision: Recurrence rates as low as 1.1% in some studies, but variable results (11.8-29%) in others 1

Non-Surgical Options for Recurrent Disease

Medical Therapies

• Adalimumab: FDA-approved for moderate to severe HS at 40mg weekly dosing (not every other week) 4

  • Recommended when conventional systemic therapy fails 1
  • Dosing: 160mg on day 1, 80mg on day 15, then 40mg weekly starting day 29 4

• Antibiotics:

  • Clindamycin 300mg twice daily with rifampicin 300mg twice daily for 10-12 weeks 1, 5
  • Doxycycline 100mg twice daily for mild to moderate disease 5

Other Interventions

• Intralesional corticosteroid injections: For carefully selected individual lesions during acute phase 1
• Acitretin: Consider in males and non-fertile females unresponsive to antibiotics 1

Treatment Algorithm Based on Disease Severity and Recurrence Pattern

For Limited Recurrence (Few Isolated Lesions)

1. First-line: Deroofing procedure or limited excision
2. Alternative: Intralesional corticosteroid injections for acute flares
3. For persistent lesions: CO2 laser excision

For Extensive Recurrence

1. First-line: Radical wide excision with appropriate reconstruction

   • Flap reconstruction for axillary, groin, or perineal areas
   • Split-thickness skin grafts for larger areas
   • Secondary intention healing for areas where cosmetic outcome is less critical

2. Medical adjuncts:

   • Adalimumab (weekly dosing) for moderate-to-severe disease
   • Clindamycin/rifampicin combination for less severe cases

Factors Affecting Surgical Outcomes

• Location: Perianal, perineal, and buttocks areas have higher complication rates (25%) 6
• Age: Younger patients have higher recurrence risk (HR 0.8) 7
• Multiple surgical sites: Increases recurrence risk (HR 1.6) 7
• Procedure type: Drainage procedures have highest recurrence risk (HR 3.5) 7
• Width of excision: More important than closure technique for preventing recurrence 1

Important Considerations

• Recurrence should be viewed as a feature of the disease rather than a failure of treatment 8
• Patients may require multiple procedures over time to maintain symptom control 8
• The British Association of Dermatologists recommends extensive excision when conventional systemic treatments have failed 1
• For axillary recurrence specifically, the Limberg transposition flap shows excellent functional and aesthetic results with low recurrence 3

Pitfalls to Avoid

• Avoid simple incision and drainage for recurrent disease as it has nearly 100% recurrence rate 1
• Avoid primary closure alone for extensive disease (69.9% recurrence) 2
• Don't underestimate the extent of disease: Ensure complete removal of all affected tissue to reduce recurrence
• Don't overlook medical therapy as an adjunct to surgical management or for patients who are poor surgical candidates

In summary, while flap surgery offers excellent outcomes for recurrent hidradenitis suppurativa, multiple other surgical and medical options exist. The choice should be based on disease extent, location, and previous treatments, with radical excision (with appropriate reconstruction) offering the lowest recurrence rates for extensive disease.