Hidradenitis suppurativa : with special reference to carbon dioxide laser surgery

Abstract

Hidradenitis suppurativa (HS) is a chronic inflammatory disease with recurrent abscesses. In most cases, it involves the axillar and anogenital regions. In industrialised countries, the prevalence is of 0.3% to 4%, and the disease is over-represented in young adult females. Various medical treatments have been used but they are seldom effective. Surgical treatment is recommended as soon as the condition is diagnosed, but wide excisions very well outside the clinical borders of activity, are mandatory. A simple local incision is of no value. According to Hurley's clinical classification, stage I consists of one or more abscesses with no sinus tract and cicatrisation and stage II consists of one or more widely separated recurrent abscesses, with a tract and cicatrisation. The severest cases (stage III) have multiple interconnected tracts and abscesses throughout an entire area.

In this thesis we report a method in which horisontal vaporisation with carbon dioxide laser is used to remove the inflamed infiltrating abscesses with precision. Patients classified as Hurley stage H were selected consecutively, in 1989 and by the year 2000 that had undergone this treatment. Most patients were females, in their twenties and thirties and had had the disease for a mean of more than ten years. By using a radical but selective, tissue-sparing technique, we removed the inflamed, foreign body-like tissues of HS, including its squamous epitheliumlined and keratin- containing sinuses. Initially, we used a free hand and more surgeondependent technique that was later abandoned for a scanner assisted technique providing better accuracy, safety and faster ablation. The use of these carbon dioxide laser, rapid beam, optomechanical scanner systems in a continuous mode gives a fast and even ablation with better visualisation of the macro- pathology during surgery. The surgical results were satisfactory cosmetically, functionally and as regards quality of life. We believe that this technique offers a safe and efficient strategy for many colleagues who treat HS.

Squamous cell carcinoma is a rare but serious complication of HS. To investigate this association and the risk of other malignancies, we performed a population-based retrospective cohort study on 2119 HS patients selected from a computerised database of hospital discharge diagnoses in Sweden during 1965-1997. We found a significantly increased risk of non- melanoma skin cancer in patients with HS. The risks of buccal cancer and primary liver cancer were also higher.

Aerobic and anaerobic cultures from superficial and deep levels were taken during laser surgery in 24 patients. In all cases, bacterial cultures were positive for one or more specimens from at least one level and from deep levels in all but three cases. Sixteen species or subspecies were found. Staphylococcus OBS aureus OBS and coagulase-negative OBS staphylococci OBS (CNS) were the most frequently found species which suggests that CNS is a true pathogen.

In our comparison of forty-two unrelated Swedish patients with HS and 250 controls we found no association with HLA-A, -B or -DRB1 alleles using the genetic tissue typing technique. Genetic factors associated with the HLA class I or II regions do not seem to contribute significantly to the possible genetic susceptibility of HS.

We also compared the release of oxygen radicals and of primary granula from in vitro activated peripheral neutrophils from HS patients with inactive disease to that from a group of healthy controls. Our findings suggest that dysfunctional neutrophils may be involved in the pathogenesis of hidradenitis suppurativa.