Extracellular matrix graft for the surgical management of hurley stage iii hidradenitis suppurativa: a pilot case series

Hidradenitis suppurativa (HS) is a debilitating, chronic inflammatory disease of the dermis.¹ The causes of HS may be a combination of genetic, endocrine, environmental and microbial factors.² Disease progression involves follicular occlusion caused by inflammation, hyperkeratosis and hyperplasia of sweat glands, and can lead to multiple abscesses and cysts in the affected area.² Histological changes in HS versus normal tissue include a thickening of the epidermis, high cellular infiltration around hair follicles and disorganised collagen fibres with a decrease in collagen III.³ Overall, systemic inflammatory markers are higher in HS than non-HS dermal diseases, such as psoriasis.⁴

Treatment of HS depends on disease severity (i.e., Hurley stage I, II and III) and includes medical treatments (for example, antibiotics, steroids and anti-inflammatories), as well as surgical interventions to remove the diseased tissue.² Recurrence is lower when therapeutic and surgical approaches are combined, compared with surgery alone.⁵ Surgical intervention for HS depends on the severity of the disease. In mild cases, local excision or deroofing of abscesses and sinuses may be sufficient.⁶ In severe cases of HS (for example, Hurley stage III) that include diffuse interconnecting tracts and abscesses across a large area, a significant surgical intervention is required, such as wide excision of the diseased tissue.⁶ Following wide excision, several reconstructive approaches are possible, including primary closure, healing via secondary intention, split-thickness skin grafting, local and free flaps.⁷ Recurrence rates after a wide excision appear lower than after local excision;⁵ however, the extent of tissue removal means that healing time is longer and complications more likely. Bouazzi et al.⁸ found that complication rates and recurrence rates remain relatively high at 25.1% and 14.0%, respectively. Ovadja et al.⁹ estimated recurrence rates for wide and partial excisions at 5% and 26%, respectively, from a meta-analysis of 125 articles. Complications associated with reconstruction after wide excision may be attributed to the poor quality of the underlying tissues (for example, fibrotic or inflamed tissue), potential for dead space between the advancing flap and underlying tissues, poor vascularity of the tissues, and associated patient comorbidities.