
==== Front
Skin Res Technol
Skin Res Technol
10.1111/(ISSN)1600-0846
SRT
Skin Research and Technology
0909-752X
1600-0846
John Wiley and Sons Inc. Hoboken

10.1111/srt.70069
SRT70069
Research Letter
Research Letter
Hidradenitis Suppurativa: Dermatopathological Insights and Surgical Success Strategies
Haque Mahfujul Z. https://orcid.org/0000-0002-4062-8818
1 haquema4@msu.edu

Ahmed Frass 1
Jodoin Zachary 2
1 Department of Medicine Michigan State University College of Human Medicine Grand Rapids Michigan USA
2 Department of Orthopedic Surgery UT Health San Antonio San Antonio Texas USA
* Correspondence: Mahfujul Z. Haque (haquema4@msu.edu)

19 9 2024
9 2024
30 9 10.1111/srt.v30.9 e7006904 9 2024
05 9 2024
© 2024 The Author(s). Skin Research and Technology published by John Wiley & Sons Ltd.
https://creativecommons.org/licenses/by/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

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cover-dateSeptember 2024
details-of-publishers-convertorConverter:WILEY_ML3GV2_TO_JATSPMC version:6.4.8 mode:remove_FC converted:20.09.2024
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pmcHidradenitis suppurativa (HS) is a debilitating skin condition with an estimated prevalence of up to 4% [1, 2, 3]. HS typically manifests in intertriginous areas and features painful abscesses, scars, and nodules [1, 2, 4]. Its systemic nature and the presence of comorbidities, such as obesity and diabetes, can complicate surgical healing [5]. HS has a strong recurrence rate as high as 35% following surgical closures, underscoring challenges in postoperative management [6]. Patients with HS more commonly experience wound dehiscence and surgical site infections, including osteomyelitis following surgical procedures such as total knee or hip arthroplasty [1]. HS has a global diagnostic delay of approximately 7.2 years, likely due to the lack of awareness among physicians [7]. Currently, there is a lack of literature addressing outcomes for patients with HS undergoing surgery. Surgeons need to be aware of exacerbating factors of HS and provide informed guidance to optimize patient health outcomes. This article outlines crucial considerations when treating patients with HS and provides evidence‐based recommendations for treating HS patients.

Perioperatively, patients require counseling about potential surgical complications, given HS's recurrent and inflammatory nature [2]. Surgeons must also focus on providing accessible resources for patient education. The HS Foundation website serves as a comprehensive resource for patients seeking information about HS and specialized HS care clinics [8]. Table 1 highlights certain HS recommendations for patients and provides a detailed list of HS specialty clinics across the United States.

TABLE 1 Recommendations for surgeons when treating patients with HS.

Circumstance	Recommendations	Resources	
Pre‐operative care: Knowledge of HS and specialty clinic	Recommend visiting the HS Foundation website.

Recommend attending HS conferences, such as the Annual Symposium on Hidradenitis Suppurativa Advances.

Provide referral to HS specialty clinic.

Recommend websites such as the HS Foundation to find nearby HS specialty clinics.

	HS Foundation (https://www.hs‐foundation.org/)

HS articles and blogs (https://www.hsconnect.org/articles

HS specialty clinics (https://www.hs‐foundation.org/hs‐specialty‐clinics)

	
Pre‐operative care: Smoking	Recommend smoking cessation and use of nicotine replacement therapy techniques such as nicotine gum, patches, or lozenges.

Recommend replacing time typically spent smoking with engaging in exercise, family, or healthy activities with friends.

	Smoking reduction interventions (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6953262/)

Quitting smoking (https://www.cdc.gov/tobacco/campaign/tips/quit‐smoking/index.html)

	
Pre‐operative care: Nutrition and diet	Recommend limiting aggravating foods such as dairy, sweets, red and processed meats, and refined carbohydrates.

Recommend consuming alleviating foods such as vegetables, fruits, chicken, seafood, and nuts.

	Nutrition, elimination diets, and HS (https://www.hsconnect.org/post/nutrition‐elimination‐diets‐and‐hs)

HS diet (https://www.healthline.com/health/hidradenitis‐suppurativa‐diet)

	
Pre‐operative care: Physical activity	Recommend breathable or loose‐fitting clothing to limit skin friction.

Recommend the use of moisture‐wicking clothing to limit sweat accumulation.

Recommend other forms of physical activity such as swimming that may be more tolerable.

Recommend immediately cleaning perspiration by showering or baby wipes

	Exercise tips for patients with HS https://www.healthcentral.com/article/exercise‐with‐hidradenitis‐suppurativa

Overview of exercising with HS https://hsdisease.com/exercise

How to exercise with HS https://hsdisease.com/living/dont‐sweat

	
Pre‐operative care: Managing comorbidities	Counsel on managing metabolic syndrome and diabetes mellitus due to their exacerbation of HS symptoms and adverse impact on surgical outcomes.

Advise on regular health monitoring and adherence to prescribed medications.

Recommend lifestyle modifications, such as a balanced diet and regular physical activity, to mitigate comorbidities' effects.

		
Perioperative care—Surgical site management strategies	Utilize non‐adherent dressings to decrease skin irritation.

Apply negative pressure wound therapy for complex wounds.

Consider silver‐impregnated dressings for their antimicrobial properties.

Practice gentle handling of skin and subcutaneous tissue to minimize trauma.

Execute surgical procedures that may involve wide excision and reconstruction with skin grafts or flaps, avoiding active or scarred HS lesions when planning the surgical site.

		
Postoperative care—pain control	Develop a balanced pain management plan to address both surgical and HS‐related pain.

Consider pharmacological therapy with agents such as adalimumab, especially for moderate to severe HS.

Explore the use of biologic agents targeting IL‐17 and IL‐12/IL‐23 for their potential in pain management.

Educate patients on pain management techniques, including the use of heat or cold therapy and relaxation techniques.

		
Postoperative care—Collaboration with dermatologists	Engage in ongoing collaboration with dermatology specialists for continuous HS management.

Follow dermatological guidance on the use of topical or systemic treatments to control HS inflammation.

Consult dermatologists for advice on postoperative skin care routines compatible with wound care.

Conduct regular dermatological assessments to promptly address HS exacerbations or complications.

		
Abbreviation: HS, Hidradenitis suppurativa.

John Wiley & Sons, Ltd.

Effective management of HS is crucial to minimize postoperative complications in surgery. HS can significantly increase the risk of infection and impede wound healing, particularly in joint replacement surgeries [1]. This increased risk necessitates a comprehensive approach to the management and counseling of HS patients. A thorough preoperative assessment should be conducted to identify active HS lesions near surgical sites, as these lesions can be focal points for infection [9].

Before any procedure, HS can be controlled preoperatively through counseling, including advising patients on smoking cessation and dietary changes. The strong association of smoking with increased HS severity and flare‐ups makes smoking cessation a key recommendation [2]. Additionally, dietary guidance should be provided, focusing on avoiding foods that trigger HS flare‐ups, particularly after surgery [2, 4]. Foods such as red meat, dairy, sweets, and refined carbohydrates should be limited, while a diet rich in vegetables, fruits, chicken, seafood, and nuts, known to alleviate HS symptoms, is encouraged [2, 4]. This dual approach of smoking cessation and dietary modification not only reduces the risk of postoperative infections but also enhances wound healing.

Another aspect of perioperative management is addressing exercise‐induced pain caused by skin friction, a common issue in HS patients [10]. To minimize friction and improve comfort, patients are advised to wear loose‐fitting, breathable fabrics [10]. Additionally, moisture‐wicking fabrics are recommended to reduce sweat accumulation and associated symptom exacerbation [10]. This is particularly important as discomfort at the surgical site during exercise may be mistakenly attributed to the procedure itself, underscoring the need to control HS in conjunction with evaluating for surgical complications.

The effective management of comorbidities such as metabolic syndrome and diabetes mellitus is essential, as these conditions can exacerbate HS symptoms and adversely impact surgical outcomes [2]. Metabolic syndrome's contribution to systemic inflammation and diabetes's role in complicating wound healing are particularly relevant in the context of surgery. Patients should receive counseling on regular health monitoring, adherence to prescribed medications, and lifestyle modifications such as a balanced diet and regular physical activity [2].

The chronic and relapsing nature of HS necessitates a comprehensive approach to surgical management [2]. For surgical site management, the literature supports several strategies tailored to HS patients. These include using non‐adherent dressings to reduce skin irritation, employing negative pressure wound therapy for complex or non‐healing wounds, and considering advanced modalities like silver‐impregnated dressings for their antimicrobial properties [11, 12, 13]. Surgeons should also consider gentle handling of the skin and subcutaneous tissue during surgery to minimize trauma to affected areas [14]. Surgical procedures for HS often involve wide excision and reconstruction with skin grafts or flaps, particularly when primary closure is not feasible [15]. Surgeons must be vigilant in their surgical site planning, avoiding areas with active or scarring HS lesions when possible.

Postoperative care should focus on wound monitoring and effective pain control. HS itself can be a source of significant pain, which may be exacerbated post‐surgery [6, 9]. Therefore, a balanced pain management plan that addresses both surgical and HS‐related pain is essential. Pharmacological therapy, such as adalimumab, has been used in conjunction with surgery for moderate to severe HS [16, 17]. Additionally, the use of biologic agents targeting IL‐17 and IL‐12/IL‐23 has shown varying efficacy in treating HS, indicating the potential role of these agents in pain management for HS patients recovering from procedures [18]. Patient education on pain management techniques, including the use of heat or cold therapy and relaxation techniques, can be beneficial for preventing flare‐ups [19]. By adequately controlling pain, patients are more likely to participate in necessary rehabilitation exercises, thereby enhancing recovery and improving overall outcomes.

The postoperative phase for patients with HS undergoing surgery demands ongoing collaboration with dermatology specialists [3]. This interdisciplinary approach ensures continuous management of HS, which is crucial for preventing flare‐ups that can complicate surgical recovery. Dermatologists can provide guidance on the use of topical or systemic treatments to control HS inflammation and prevent new lesion formation that is compatible with postoperative healing [3]. Regular dermatological assessments can help in promptly identifying and addressing any HS exacerbations or complications. Collaborative care not only aids in the effective management of HS but also supports the overall healing process, contributing to successful surgical outcomes.

HS when coupled with surgical procedures, presents unique challenges due to its increased risk of infection, complications in wound healing, and the complex interplay with comorbidities. Thorough preoperative assessments, lifestyle modifications, and careful surgical site management are pivotal in minimizing postoperative complications. Addressing exercise‐induced discomfort, effective pain management, and the critical role of dermatological collaboration can enhance patient care. These insights offer a pathway for surgeons to provide effective care, contributing significantly to the holistic well‐being and recovery of this patient population.

Ethics Statement

This study analyzed publicly available, anonymized internet data. No primary data collection involving human participants was conducted, and therefore, no ethical approval or consent procedures were required.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.
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References

1 M. J. Gouzoulis , A. J. Kammien , D. L. Caruana , D. H. Wiznia , and J. N. Grauer , “Hidradenitis Suppurativa Leads to Increased Risk of Wound‐Related Complications Following Total Joint Arthroplasty,” Arthroplasty Today 16 (2022): 169–174, 10.1016/j.artd.2022.05.013.35789782
2 A. Alikhan , C. Sayed , A. Alavi , et al., “North American Clinical Management Guidelines for Hidradenitis Suppurativa: A Publication From the United States and Canadian Hidradenitis Suppurativa Foundations: Part I: Diagnosis, Evaluation, and the Use of Complementary and Procedural Management,” Journal of the American Academy of Dermatology 81 , no. 1 (2019): 76–90, 10.1016/j.jaad.2019.02.067.30872156
3 O. Büyükaşik , A. O. Hasdemir , N. Kahramansoy , C. Çöl , and H. Erkol , “Surgical Approach to Extensive Hidradenitis Suppurativa,” Dermatologic Surgery 37 , no. 6 (2011): 835–842, 10.1111/j.1524-4725.2011.01961..x.21605246
4 J. M. Fernandez , K. D. Marr , A. J. Hendricks , et al., “Alleviating and Exacerbating Foods in Hidradenitis Suppurativa,” Dermatologic Therapy 33 , no. 6 (2020): e14246, 10.1111/dth.14246.32860476
5 A. B. Kimball , M. Sundaram , G. Gauthier , et al., “The Comorbidity Burden of Hidradenitis Suppurativa in the United States: A Claims Data Analysis,” Dermatology and Therapy 8 , no. 4 (2018): 557–569, 10.1007/s13555-018-0264-z.30306395
6 L. Fertitta , C. Hotz , P. Wolkenstein , et al., “Efficacy and Satisfaction of Surgical Treatment for Hidradenitis Suppurativa,” Journal of the European Academy of Dermatology and Venereology 34 , no. 4 (2020): 839–845, 10.1111/jdv.16135.31799758
7 L. Howells , N. Lancaster , M. McPhee , et al., “Thematic Synthesis of the Experiences of People With Hidradenitis Suppurativa: A Systematic Review,” British Journal of Dermatology 185 , no. 5 (2021): 921–934, 10.1111/bjd.20523.34050935
8 HS Foundation , accessed September 17, 2024, https://www.hs‐foundation.org/.
9 C. C. Zouboulis , V. D. Marmol , U. Mrowietz , E. P. Prens , T. Tzellos , and G. B. E. Jemec , “Hidradenitis Suppurativa/Acne Inversa: Criteria for Diagnosis, Severity Assessment, Classification and Disease Evaluation,” Dermatology 231 , no. 2 (2015): 184–190, 10.1159/000431175.26139027
10 T. Y. Loh , A. J. Hendricks , J. L. Hsiao , and V. Y. Shi , “Undergarment and Fabric Selection in the Management of Hidradenitis Suppurativa,” Dermatology 237 , no. 1 (2019): 119–124, 10.1159/000501611.31466052
11 M. C. Stumpfe , R. E. Horch , A. Arkudas , et al., “The Value of Negative‐Pressure Wound Therapy and Flap Surgery in Hidradenitis Suppurativa—A Single Center Analysis of Different Treatment Options,” Frontiers in Surgery 9 (2022): 867487, https://www.frontiersin.org/articles/10.3389/fsurg.2022.867487.35836613
12 D. P. Singh , A. Gabriel , R. P. Silverman , L. Griffin , L. D. McGowan , and R. B. D'Agostino , “Meta‐Analysis Comparing Outcomes of Two Different Negative Pressure Therapy Systems in Closed Incision Management,” Plastic and Reconstructive Surgery Global Open 7 , no. 6 (2019): e2259, 10.1097/gox.0000000000002259.31624675
13 E. C. Abboud , J. C. Settle , T. B. Legare , J. E. Marcet , D. J. Barillo , and J. E. Sanchez , “Silver‐Based Dressings for the Reduction of Surgical Site Infection: Review of Current Experience and Recommendation for Future Studies,” Burns 40 , no. Suppl 1 (2014): S30–39, 10.1016/j.burns.2014.09.011.25418436
14 L. Iskandar , L. Di‐Silvio , J. Acheson , and S. Deb , “Dual Network Composites of Poly(vinyl Alcohol)‐Calcium Metaphosphate/Alginate With Osteogenic Ions for Bone Tissue Engineering in Oral and Maxillofacial Surgery,” Bioengineering 8 , no. 8 (2021): 107, 10.3390/bioengineering8080107.34436110
15 M. Gierek , G. Ochała‐Gierek , D. Kitala , W. Łabuś , and B. Bergler‐Czop , “Surgical Management of Hidradenitis Suppurativa,” Postepy Dermatologii i Alergologii 39 , no. 6 (2022): 1015–1020, 10.5114/ada.2022.115323.36686007
16 F. G. Bechara , M. Podda , E. P. Prens , et al., “Efficacy and Safety of Adalimumab in Conjunction With Surgery in Moderate to Severe Hidradenitis Suppurativa,” Jama Surgery 156 , no. 11 (2021): 1001–1009, 10.1001/jamasurg.2021.3655.34406349
17 P. Guillem , C. Perat , and V. Vlaeminck‐Guillem , “Can Adalimumab Reduce the Extent of Hidradenitis Suppurativa Surgery?,” Jama Surgery 157 , no. 6 (2022): 552–553, 10.1001/jamasurg.2022.0083.35262636
18 N. Gutierrez and P. R. Cohen , “Ectopic Hidradenitis Suppurativa: Case Report and Review of Literature,” Cureus 13 , no. 1 (2021): e12966, 10.7759/cureus.12966.33659117
19 F. Sampogna , D. Abeni , U. Gieler , et al., “Exploring the EQ‐5D Dimension of Pain/Discomfort in Dermatology Outpatients From a Multicentre Study in 13 European Countries,” Acta Dermato Venereologica 100 , no. 8 (2020): adv00120, 10.2340/00015555-3477.32250441
20 A. Alikhan , P. Lynch , and D. B. Eisen , “Hidradenitis Suppurativa: A Comprehensive Review,” Journal of the American Academy of Dermatology 60 , no. 4 (2009): 539–563, 10.1016/j.jaad.2008.11.911.19293006
