Deroofing: A tissue-saving surgical technique for the treatment of mild to moderate hidradenitis suppurativa lesions

      Background

      Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease, often refractory to treatment. Patients with HS and dermatologists are in need of an effective, fast surgical intervention technique. Deroofing is a tissue-saving technique, whereby the “roof” of an abscess, cyst, or sinus tract is electrosurgically removed. The use of a probe is mandatory to explore the full extent of a lesion.

      Objective

      We sought to evaluate the efficacy and patient satisfaction of the deroofing technique for recurrent Hurley I (mild) or II (moderate) graded HS lesions at fixed locations.

      Methods

      An open study consisted of 88 deroofed lesions in 44 consecutive patients with HS, treated by a single clinician with a follow-up time of up to 5 years.

      Results

      Fifteen of 88 (17%) treated lesions showed a recurrence after a median of 4.6 months. In all, 73 treated lesions (83%) did not show a recurrence after a median follow-up of 34 months. The median patient satisfaction with the procedure rated 8 on a scale from 0 to 10. Of the treated patients, 90% would recommend the deroofing technique to other patients with HS. One side effect occurred in the form of postoperative bleeding.

      Limitations

      Some patients were lost to follow-up.

      Conclusions

      The deroofing technique is an effective, simple, minimally invasive, tissue-saving surgical intervention for the treatment of mild to moderate HS lesions at fixed locations and it is suitable as an office procedure.

      Key words

      See commentary on page481
      • Hidradenitis suppurativa is difficult to treat; simple incision and drainage has a high recurrence rate.
      • Mild to moderate inflamed hidradenitis suppurativa lesions frequently occur at fixed body locations.
      • For above-defined lesions, the surgical deroofing technique is tissue-saving and effective with limited recurrence and good long-term results.
      • Deroofing is suitable as an office procedure.
      Hidradenitis suppurativa (HS) is a chronic, inflammatory, recurrent, debilitating follicular skin disease that usually presents after puberty with painful deep-seated, inflamed lesions in the apocrine gland-bearing areas of the body, most commonly the axillary, inguinal, and anogenital regions.
      • Revuz J.
      Hidradenitis suppurativa.
      Prevalence rates of up to 4% have been estimated.
      • Alikhan A.
      • Lynch P.J.
      • Eisen D.B.
      Hidradenitis suppurativa: a comprehensive review.
      This painful disorder deeply affects the quality of life of affected patients.
      • Wolkenstein P.
      • Loundou A.
      • Barrau K.
      • Auquier P.
      • Revuz J.
      Quality of Life Group of the French Society of Dermatology. Quality of life impairment in hidradenitis suppurativa: a study of 61 cases.
      The exact pathogenesis of HS remains largely unknown and is probably multifactorial.
      • Kurzen H.
      • Kurokawa I.
      • Jemec G.B.
      • Emtestam L.
      • Sellheyer K.
      • Giamarellos-Bourboulis E.J.
      • et al.
      What causes hidradenitis suppurativa?.
      The primary mechanism in the disease is thought to be hyperkeratinization of the pilosebaceous infundibulum resulting in occlusion of the follicle followed by its rupture with subsequent inflammation.
      • Boer J.
      • Jemec G.B.
      Resorcinol peels as a possible self-treatment of painful nodules in hidradenitis suppurativa.
      To date, HS remains difficult to treat, with often unsatisfactory clinical results. Current pharmaceutical options include topical or oral antibiotics, hormonal therapies, anti– tumor necrosis factor-alfa biologics,
      • Revuz J.
      Hidradenitis suppurativa.
      and topical resorcinol.
      • Boer J.
      • Jemec G.B.
      Resorcinol peels as a possible self-treatment of painful nodules in hidradenitis suppurativa.
      Retinoids in the form of oral isotretinoin have limited clinical efficacy.
      • Revuz J.
      Hidradenitis suppurativa.
      In addition to pharmaceutical drugs, surgical interventions are often used. Surgical interventions include incision with drainage, limited excision using cold steel
      • Jemec G.B.
      Effect of localized surgical excisions in hidradenitis suppurativa.
      or electro surgery, and carbon-dioxide laser evaporation.
      • Madan V.
      • Hindle E.
      • Hussain W.
      • August P.J.
      Outcomes of treatment of nine cases of recalcitrant severe hidradenitis suppurativa with carbon dioxide laser.
      • Lapins J.
      • Sartorius K.
      • Emtestam L.
      Scanner-assisted carbon dioxide laser surgery: a retrospective follow-up study of patients with hidradenitis suppurativa.
      Sometimes large skin areas are excised en bloc. Defects may be sutured; closed with grafts, or local or distant flaps; or left open for healing by secondary intention. Rigorous surgery is considered to be more effective than treatments with drugs and conservative surgery. The treatment of choice depends on severity, disease course, and the wishes or preferences of the patient. In chronic, severe cases, surgery is considered mandatory.
      • Revuz J.
      Hidradenitis suppurativa.
      In mild and moderate HS, patients may benefit from topical or systemic treatment, surgery, or not uncommonly, a combination of both. Treating the disease at an early stage is considered essential as delay in treatment could lead to a situation where disease activity gets out of control making wide surgical excision necessary. There is a need for an effective and fast surgical technique, other than simple incision and drainage, which is suitable as an office procedure. We therefore propose the deroofing technique. This technique converts, with limited surgery and maximal preservation of the surrounding healthy tissue, painful recurrent lesions into cosmetically acceptable scars. The deroofing technique was first described by Mullins et al
      • Mullins J.F.
      • McCash W.B.
      • Boudreau R.F.
      Treatment of chronic hidradenitis suppurativa; surgical modification.
      as early as 1959. Ever since, deroofing has been mentioned in many reviews and dermatology textbooks but its efficacy has never been properly investigated. Nevertheless dermatologists in The Netherlands adopted this technique and it is now widely used and yielding positive results, which were mostly published as case reports.
      • Van der Plas M.
      • Bos W.H.
      Chirurgische behandeling van hidradenitis suppurativa (epitheliale adnex cysten) door de dermatoloog.
      • van der Wal V.B.
      • Bos W.H.
      Chirurgische behandeling van acne ectopica met “deroofing”(methode Bos): 1994-1999.
      • Boer J.
      • Bos W.H.
      • Meer van der J.B.
      Hidradenitis suppurativa (acne inversa): behandeling met deroofing en resorcinol.
      Therefore, the aim of this study was to evaluate the efficacy and patient satisfaction of the deroofing technique in a larger population of patients with HS. Here, we report the results of an open study on the deroofing intervention in 44 patients with Hurley grade I and II, with a follow-up of up to 5 years.

      Methods

      In all, 44 consecutive patients with HS were treated in an open trial with the deroofing technique in the outpatient Department of Dermatology, Deventer Hospital, The Netherlands, in the period 2003 to 2007. The criteria used to establish the diagnosis of HS were: presence of typical lesions (ie, deep-seated painful nodules, abscesses, draining sinuses, bridged scars, and “tombstone” open comedones in secondary lesions); typical topography (ie, axillae, groin, perineal and perianal region, buttocks, and inframammary and intermammary folds); and a history of chronicity and recurrences.
      • Revuz J.
      Hidradenitis suppurativa.
      The physical examination, the decision to perform deroofing intervention, and follow-up were all done by the same investigator (J. B.). Descriptive staging of the disease severity according to Hurley
      • Hurley H.J.
      Axillary hyperhidrosis, apocrine bromhidrosis, hidradenitis suppurativa, and familial benign pemphigus: surgical approach.
      was made in all patients: stage 1–abscess formation, single or multiple, without sinus tracts and cicatrization; stage 2–recurrent abscesses with tracts and scar formation, single or multiple, widely separated lesions; and stage 3–diffuse or near diffuse involvement or multiple interconnected tracts or abscesses across the entire area. The following questions were always asked: Are recurrences of the HS lesions located at exactly the same fixed locations? At various locations? Or a combination of both? Lesions at fixed locations and assessed as Hurley I or II were considered suitable for deroofing. All patients gave their informed consent. Age, age at onset of the disease, sex, body mass index, treated area, length of the created defect, patient-reported healing time, complications, and recurrences at follow-up were recorded and monitored. All patients were initially seen 6 weeks after deroofing. Patients were asked the number of days required for complete closure of the surgical defect. At each follow-up visit, the patient was asked whether a recurrence had occurred and the deroofed site was inspected for signs of recurrence. A recurrence was defined as an inflammatory boil in or less than 0.5 cm adjacent to the scar. The patients were interviewed by telephone in 2008 or 2009 for their views on the long-term outcomes of the deroofing treatment. The questionnaire consisted of the following questions: “On a scale of 1-10 how satisfied are you with the treatment (0, very dissatisfied; 10, very satisfied)?” and “Would you recommend this treatment to other patients with HS?” The telephone interview was conducted by one of the authors (H. H. v. d. Z.).

       The deroofing technique

      Preoperatively HS lesions to be deroofed were identified by visual inspection and palpation, and were marked with ink (Fig 1). The skin was disinfected with 0.05 mg/mL of chlorhexidine solution. Local anesthesia was performed in two steps. First, anesthesia solution, lidocaine 1% (10 mg/mL) plus adrenaline (5 μg/mL) was injected to infiltrate the surrounding area. Secondly, the nodule and/or sinus tract was also injected with the same local anesthetic. The latter procedure provides good demarcation of the extent of the lesion. Because the anesthesia injections were experienced as painful, in some cases an eutectic mixture of lidocaine and prilocaine cream (EMLA) was applied 1 hour before the injections. For electrosurgical cutting, the Erbotom ICC50 (Erbe Surgical Systems, Marietta, GA) operating at 35 W, with a manually controlled hand piece fitted with a loop was used. A hyfrecator with a sharp tip and used in the fulguration mode would probably give a comparable effect. A blunt probe was inserted in sinus openings that were discharging purulent exudate. In case openings were not detectable a small incision was made to introduce the probe. The lesion was then explored with the probe in all directions to find and explore all communicating tracts (Fig 2). It was common to find considerable areas of undermined skin with tracks sometimes running at different depths (Fig 3). Care was taken not to create false passages with the probe. In case a blunt probe is not available the blunt tip of a closed, fine forceps or “mosquito” could be used as a probe. Then the roof of the lesion was surgically removed using the probe as a guide, leaving the floor of the lesion exposed (Fig 4). The walls were carefully probed again for other remaining communicating sinus tracts, so as not to miss those tracts. The gelatinous and sanguinolent material on the floor of the exposed and inflamed lesions was carefully scraped away with a disposable curette. The created defects were left open for healing by secondary intention. Postoperative wound care consisted of once daily application of mupirocin ointment in the defect, together with a soft silicone wound contact layer dressing that served as a wedge to keep the wound open, for 5 days. Thereafter the patient switched to application of daily dressings consisting of iodine ointment–containing gauzes until the defect was closed. Patients were instructed to rinse the defect twice daily in the shower. Generally the defects healed into cosmetically acceptable scars (Fig 5).
      Figure thumbnail gr1
      Fig 1Draining hidradenitis suppurativa nodule, located in groin (patient 1).
      Figure thumbnail gr2
      Fig 2Blunt probe is inserted to explore extent of lesion (patient 1).
      Figure thumbnail gr3
      Fig 3Sinus tracts can be unexpectedly long (patient 2).
      Figure thumbnail gr4
      Fig 4Roof of lesion is removed and left for healing by second intention, after removal of debris by curette (patient 2).
      Figure thumbnail gr5
      Fig 5Hidradenitis suppurativa lesion healed into cosmetically acceptable scar. Result after 1 year (patient 1).

      Results

      In all, 44 patients with HS, 3 male and 41 female, with a total of 88 lesions underwent deroofing during the investigated period. No deroofed cases were excluded from the study. Patient characteristics are given in Table I. All patients had a history of active long-standing HS. The median age of disease onset was 28 years. The median age at time of deroofing was 35 years with a median body mass index of 26.8.
      Table IPatient characteristics
      Patients, n = 44 (41 female, 3 male)Median (interquartile range)
      Age of disease onset, y28 (20-37)
      Age, y35 (28-43)
      Body mass index26.8 (22.3-30.9)
      Lesion characteristics are given in Table II. Most of the deroofed lesions (41 [47%]) were located in the groin followed by the axillae (39 lesions [44%]). Eight treated lesions were located on the buttocks. The mean length of the created defect was 3.0 cm. The mean healing time was 14 days. Fifteen of 88 (17%) deroofed lesions showed a recurrence, after a median of 4.6 months (interquartile range 1.2-6.2). In all, 73 deroofed lesions (83%) did not show a recurrence after a median follow-up of 34 months (interquartile range 24-44). One complication occurred in the form of postoperative bleeding. No infections were observed, nor was impairment of movement caused by postoperative scarring. Of 44 patients, 37 (84%) were contacted and interviewed by telephone; 7 patients could not be traced by any means and were considered lost to follow-up. The median satisfaction rate for deroofing was 8.0. Patients without a recurrence evaluated the technique higher than patients with a recurrence (8.0 vs 7.0, respectively). Of treated patients, 90% would recommend the deroofing technique to other patients with HS (Table III). Interestingly, patients with recurrence recommended the procedure almost as frequently as patients without recurrence (92% vs 82%).
      Table IICharacteristics of treated lesions
      Treated lesionsn = 88
      Location of treated lesionsAxillae 44.3%
      Groin 46.6%
      Buttocks 9.1%
      Size of defect directly postoperatively, cm3.0 ± 1.7
      Mean ± SD.
      (range 1-10)
      Healing time, d14.1 ± 7.8
      Mean ± SD.
      (range 2-35)
      Mean ± SD.
      Table IIIPatient satisfaction with deroofing procedure
      All patients n = 44No recurrence n = 29Recurrence n = 15
      Satisfaction score (0-10)8 (7-9)
      Median and interquartile range.
      8 (7-9)
      Median and interquartile range.
      7 (4-8)
      Median and interquartile range.
      Score < 616%8%36%
      Recommending deroofing to other patients90%92%82%
      Median and interquartile range.

      Discussion

      The treatment repertoire for HS consists of medical (topical, systemic) and surgical interventions. Early intervention is considered mandatory to prevent disease activity from getting out of control with consequences such as fibrosis, scarring, and sinus tract formation causing therapy resistance and major quality-of-life impairment. Several surgical interventions have been described for HS often with considerable recurrence rates. The reported recurrence rates after incision with drainage are almost 100%; for limited excision using cold steel, 43%; and for wide excisions, 27%.
      • Ritz J.P.
      • Runkel N.
      • Haier J.
      • Buhr H.J.
      Extent of surgery and recurrence rate of hidradenitis suppurativa.
      Here we show that after a median follow-up of 34 months from 88 deroofed lesions, 83% did not recur. Systematic comparison of studies is hampered by variable definitions of recurrence. The deroofing technique, as used in this study, was first described in 1959 by Mullins et al.
      • Mullins J.F.
      • McCash W.B.
      • Boudreau R.F.
      Treatment of chronic hidradenitis suppurativa; surgical modification.
      In 1983 Culp
      • Culp C.E.
      Chronic hidradenitis suppurativa of the anal canal: a surgical skin disease.
      reported on deroofing in a group of 30 patients with HS of the anal region. Unfortunately recurrences and follow-up were not studied and the diagnosis of HS was questionable. However, a novelty was that in contrast to Mullins et al,
      • Mullins J.F.
      • McCash W.B.
      • Boudreau R.F.
      Treatment of chronic hidradenitis suppurativa; surgical modification.
      Culp
      • Culp C.E.
      Chronic hidradenitis suppurativa of the anal canal: a surgical skin disease.
      left the floor of the exposed lesions untouched. The authors stated that preservation of the exposed lesion floor was essential for its epithelial regenerative elements. In 1986, Brown et al
      • Brown S.C.
      • Kazzazi N.
      • Lord P.H.
      Surgical treatment of perineal hidradenitis suppurativa with special reference to recognition of the perianal form.
      presented 3 HS cases treated with deroofing. In their opinion, like Culp,
      • Culp C.E.
      Chronic hidradenitis suppurativa of the anal canal: a surgical skin disease.
      epithelial cells from sweat glands and hair follicle remnants were present in the debris and at the floor of the exposed lesion, which could rapidly re-epithelize the defect. We agree with Mullins et al
      • Mullins J.F.
      • McCash W.B.
      • Boudreau R.F.
      Treatment of chronic hidradenitis suppurativa; surgical modification.
      that the debris on the floor should be removed, because keratinous debris or viable epithelial remnants could get entrapped deep within the dermis when not removed and may cause recurrence.
      • Lapins J.
      • Sartorius K.
      • Emtestam L.
      Scanner-assisted carbon dioxide laser surgery: a retrospective follow-up study of patients with hidradenitis suppurativa.
      It is known that other sites for recurrences are not radically excised lesions, which appear to be the major cause for recurrence after conventional surgery.
      • Slade D.E.
      • Powell B.W.
      • Mortimer P.S.
      Hidradenitis suppurativa: pathogenesis and management.
      Excision of HS lesions should be done en bloc with all its communicating sinus tracts. Therefore we argue that the use of a probe is mandatory. Of our deroofed patients, 90% would recommend deroofing to other patients with HS. This was the same percentage as that of Madan et al,
      • Madan V.
      • Hindle E.
      • Hussain W.
      • August P.J.
      Outcomes of treatment of nine cases of recalcitrant severe hidradenitis suppurativa with carbon dioxide laser.
      who treated 9 patients with HS using the carbon-dioxide laser. They achieved a total clearance in 7 of 9 patients (78%) after 12 months of follow-up, and a patient satisfaction rate of 8.5 in contrast to 8.0 with deroofing. In comparison with our method, Madan et al
      • Madan V.
      • Hindle E.
      • Hussain W.
      • August P.J.
      Outcomes of treatment of nine cases of recalcitrant severe hidradenitis suppurativa with carbon dioxide laser.
      treated all HS lesions in one session under general anesthesia. In contrast to deroofing, carbon-dioxide laser treatment is more time-consuming, rather expensive, and must be performed by experienced hands. Recently Aksakal and Adişen
      • Aksakal A.B.
      Adişen E. Hidradenitis suppurativa: importance of early treatment; efficient treatment with electrosurgery.
      reported on the use of electrosurgery for HS areas assessed as Hurley I and II. Thirty lesions in 12 patients were treated. The efficacy of the technique was measured by postoperative wound infection; recurrence rate was, however, not reported. In comparison with the deroofing technique, Aksakal and Adişen
      • Aksakal A.B.
      Adişen E. Hidradenitis suppurativa: importance of early treatment; efficient treatment with electrosurgery.
      did not use a probe. This approach resembles normal excision with cold steel and is therefore less tissue-saving. Because of the pathophysiology of HS, new lesions can always occur in the predisposed HS areas. Some HS lesions spontaneously resolve, never to come back at the exact location. Another type of HS lesion stays at exactly the same location, is a nontender nodule when in remission, but can flare periodically. This last type of lesion is especially suited for deroofing. Deroofing of such lesions can be applied both when it is inflamed or in remission. Lesions in Hurley III areas are not deroofed in this way in our clinic, because we argue that deroofing does not add any advantages in these cases. In our opinion these areas can only be treated with radical wide excision, mostly under general anesthesia. Because the deroofing technique does not take much time, our patients with HS are generally deroofed during the same consultation in which they present with their lesions. We argue that early intervention with deroofing can prevent disease aggravation, and so prevent radical surgery. The deroofing technique generally makes small defects so no general anesthesia is needed. In addition, single-lesion surgical treatment offers low morbidity and moreover the chance of creating unacceptable cosmetic results is clearly diminished and scar contractures are prevented. This is supported by the high patient satisfaction rate and recommending rate. Because of the use of the electrosurgical loop good hemostasis is achieved, allowing good visualization of the operative area. In conclusion, the deroofing method is easy to conduct and cheap. We provide evidence that it is safe to conduct with prolonged effectiveness for recurrent HS lesions at fixed locations in Hurley I or II areas. We argue that the deroofing technique is superior over incision with drainage and simple excisions with cold steel.
      We thank Jon D. Laman for his critical reading of the manuscript.

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