Hidradenitis suppurativa (HS) is a physically debilitating disease that greatly impairs the quality of life of affected individuals. Advanced disease is often difficult to treat with topical and systemic therapies. Surgical resection of diseased skin has become paramount in HS management but proposes challenges of wound care and closure.

HS management but proposes challenges of wound care and closure. Four patients with a total of 12 complex wounds were treated over a three-year period. All the patients were males between the ages of 28 and 61 years.

The lesions were located on the buttocks (n=5), chest (n=1), perianal (n=2), perineal (n=2), and axillary regions (n=2). A protocol of wide local excision, followed by negative pressure wound therapy with instillation and dwell time (NPWTi-d) to decrease bioburden and promote angiogenesis of the exposed base, and subsequent skin grafting was used. Patients remained hospitalized between procedures.

The original wound area ranged from 210-540 cm2. Skin grafts of comparable sizes were taken from donor sites. The average duration of NPWTi-d placement was 3.5 days and the average time from excision to wound coverage was 4.3 days.

The percent of graft uptake ranged from 70%-90%. All patients were resolved of their local disease with no complications.

Surgical management of HS

Surgical management of HS can be complicated by difficult closures. This case series demonstrates that wide local excision followed by NPWTi-d and skin grafting can achieve local resolution of disease in HS patients who have failed multiple minimally invasive therapies.

Other surgical treatment methods for HS include the use of local or perforator flaps and recycled skin grafts. Local and perforator flaps yield successful results in select patient populations, such as patients with small to moderate sized defects.

However, both methods have significant morbidities and donor site limitations. The excision of advanced HS creates large skin defects, local or perforator flaps may not be adequate for the reconstruction of these defects.

The recycled skin graft method was described to decrease the donor site morbidity associated with split-thickness skin grafts. The skin over the diseased area is harvested as a split-thickness skin graft and reused to cover the defect resulting from the surgical excision of HS. 

Wounds were covered with skin grafts in a second stage operation. Moreover, reconstructing the defect with the same, chronically infected skin may theoretically increase the risk of postoperative wound infection leading to graft loss.