Severe Acne Inversa - Dermatosurgical Approach in a Bulgarian Patient
AbstractWe present a 55-year-old male patient - a smoker, admitted to a Medical Institute of MVR (Ministry of the interior, Sofia, Bulgaria), on occasion of pain and swellings, located in the area of both axillae, accompanied by purulent discharge, with bloody admixtures. Bilateral localised cystic rose above the skin surface, hyperpigmented nodules interconnected with multiple fistulas, was observed within the dermatological examination, resulting in a limitation of the possibility of movement of the hands in all directions. A subjective complaint of pain was obtained on palpation. Solid bilateral axillar cicatrices - formation was also established, which additional impeded the movements of the upper limbs. The disease was generalised affecting additional inguinal, femoral and perineal areas, while at this stage the patient refused categorically eventual photo documentation of them. The diagnosis of acne inversa was made based on the available clinical and para-clinical data, as dual antibiotic therapy with Clindamycin 300 mg, two times per day was initiated for two months, in combination with rifampicin 300 mg, two times per day also for two months. This led to a significant improvement in the clinic symptoms and the patient was hospitalised for radical surgery. A surgical management of the clinical findings was planned by an interdisciplinary team including surgeons and dermatologists. The procedure was performed under general anaesthesia. After a thorough cleaning of the operative field, a radical excision of the lesion in the left axillary and para axillar region was performed, comprising the skin and subcutaneous tissue forward the fascia pectoralis. Tissue was dissected in depth in the form of number 4, thereby creating the conditions for adaptation of the initially encountered communicating with each other skin defects. Two tubular drains were placed, followed by gradual suturing of skin and subcutaneous tissue with final applying of a sterile dressing. Effective medical treatment of patients (as in our case) with severe AI is limited. Adalimumab is the first biological approved for moderate to severe AI but does not result in stable CR (cure rate). Therefore its use in a neoadjuvant setting is under investigation. Wide local excision significantly reduces pain and improves the quality of life of AI patients. While local recurrences rate is low, the satisfaction with the cosmetic results is high. The recurrence rate is dependent on the region affected and the type of surgery. While in the axillary region primary closure may be used to reduce the time to healing, anogenital AI has the lowest recurrence rate of healing by secondary intention.
Plum Analytics Artifact Widget Block
Wollina U, Koch A, Heinig B, Kittner T, Nowak A. Acne inversa (Hidradenitis suppurativa): A review with a focus on pathogenesis and treatment. Indian Dermatol Online J. 2013;4(1):2-11. https://doi.org/10.4103/2229-5178.105454 PMid:23439959 PMCid:PMC3573446
Andersen RK, Jemec GB. Treatments for hidradenitis suppurativa. Clin Dermatol. 2017;35(2):218-224. https://doi.org/10.1016/j.clindermatol.2016.10.018 PMid:28274363
Zouboulis CC, Desai N, Emtestam L, Hunger RE, Ioannides D, JuhÃ¡sz I, Lapins J, Matusiak L, Prens EP, Revuz J, Schneider-Burrus S, Szepietowski JC, van der Zee HH, Jemec GB. European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa. J Eur Acad Dermatol Venereol. 2015;29(4):619-44. https://doi.org/10.1111/jdv.12966 PMid:25640693
Wollina U, Langner D, Heinig B, Nowak A. Comorbidities, treatment, and outcome in severe anogenital inverse acne (hidradenitis suppurativa): a 15-year single center report. Int J Dermatol. 2017;56(1):109-115. https://doi.org/10.1111/ijd.13393 PMid:27495143
Fabbrocini G, Ruocco E, De Vita V, Monfrecola G. Squamous cell carcinoma arising in long-standing hidradenitis suppurativa: An overlooked facet of the immunocompromised district. Clin Dermatol. 2017;35(2):225-227. https://doi.org/10.1016/j.clindermatol.2016.10.019 PMid:28274364
Ingram JR. Interventions for hidradenitis suppurativa: updated summary of an original Cochrane Review. JAMA Dermatol. 2017; https://doi.org/10.1001/jamadermatol.2017.0432
Wollina U, Tilp M, Meseg A, SchÃ¶nlebe J, Heinig B, Nowak A. Management of severe anogenital acne inversa (hidradenitis suppurativa). Dermatol Surg. 2012;38(1):110-7. https://doi.org/10.1111/j.1524-4725.2011.02157.x PMid:22092781
Posch C, Monshi B, Quint T, Vujic I, Lilgenau N, Rappersberger K. The role of wide local excision for the treatment of severe hidradenitis suppurativa (Hurley grade III): Retrospective analysis of 74 patients. J Am Acad Dermatol. 2017; pii: S0190-9622(17)30149-4.
All rights reserved.