24 Massive perianal hidradenitis suppurativa: aggressive surgical approach with curative intent

Abstract Aim Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease affecting areas rich in apocrine glands (for example groin, axillae), causing significant disability. Clinical manifestations include the formation of painful suppurative nodules, leading to recurrent abscesses extending deeply into the subcutaneous tissue, ultimately developing interconnecting sinus tracts, and resulting in hypertrophic scarring. This condition imposes substantial physical and psycho-social distress on patients, along with an economic burden due to the need for chronic care. Although the pathogenesis is not fully understood, HS is considered an androgen-dependent pathology associated with endocrine abnormalities, with risk factors such as smoking and obesity exacerbating its severity. Bacterial infection is viewed as a secondary phenomenon. This case-report aims to present a case of massive perianal HS and emphasize the efficacy of an aggressive surgical intervention with the intention of achieving a curative outcome. Methods We report the case of a 45-year-old Caucasian woman with a history of active smoking, alcoholism, and depression. The patient described recurrent perianal abscesses years ago, experiencing progressive symptoms with multiple episodes of abscesses that needed drainage in the Emergency Department. Due to the COVID-19 pandemic, regular follow-ups were interrupted for over a year, leading to clinical deterioration of the perianal disease. Upon emergency admission, the patient exhibited bilaterally encrusted perianal plaques extending to the buttocks, with multiple actively draining fistulas. Drainage, biopsies, and seton placement were performed. A differential diagnosis between HS and Crohn’s Disease was considered. Further investigations included imaging studies, colonoscopy, specific biopsies, and laboratory tests. Evaluation by Gastroenterology and Dermatology ruled out inflammatory bowel disease, and confirmed HS. Results Despite initial attempts at medical management by Dermatology, the patient’s deteriorating quality of life prompted a decisive surgical approach by Colorectal and Plastic Surgery. Bilateral excision of the affected perianal region was performed down to healthy subcutaneous tissue. Anal canal and introitus exploration revealed no identifiable tracts. Anal and vulvar margins were preserved to avoid tissue retraction. Primary closure was achieved in the posterior buttock and bilateral inguinal regions, leaving the central subcutaneous area exposed. Following local care for several weeks to promote granulation, Plastic Surgery considered a skin graft to cover the exposed region. Conclusions HS may manifest insidiously, needing an accurate differential diagnosis and interdisciplinary management and follow-up. Initial treatment involves antibiotics, topical antiseptics, or intralesional corticosteroids. Some medications (retinoids, anti-androgen therapy, immunotherapy, oral immunosuppressants) have shown positive effects on disease progression. However, for many cases of advanced disease, radical surgery may be the only curative option, as in the case presented. Early and extensive surgical excision is crucial for preventing complications and recurrence, ultimately improving the quality of life for these patients.