Comparing Effective Wound Closures in Hidradenitis Suppurativa Surgery

Image Credit: © DermNet

In cases where traditional therapy fails to control mild to moderate hidradenitis suppurativa (HS), various surgical techniques, including punch debridement, unroofing, and electrosurgery, have been utilized. For severe disease (Hurley stage II/III), chronic inflammation results in irreversible damage, tunneling, and scarring. In these scenarios, researchers have found systemic therapies often provide inadequate relief, necessitating wide surgical excision.¹ This technique involves removing the affected dermis and subcutaneous tissue with a margin of healthy skin, offering longer disease-free intervals.

A key challenge following wide excision is determining the most effective wound closure method. Options include:

• Primary closure
• Split-thickness skin grafts
• Local/distant flaps
• Secondary intention healing

A recent systematic review and meta-analysis evaluated recurrence rates, patient outcomes, and complication risks associated with these methods to determine the efficacy and safety of each option.²

“While simpler and faster than the secondary closure technique, the primary closure technique showed higher recurrence rates, likely because of its limited capacity to manage the extensive tissue defects and residual inflammation characteristic of HS,” researchers stated. “Secondary intention healing, although not significantly reducing recurrence rates compared to primary closure, offers the advantage of avoiding donor site morbidity and maintaining a reasonable range of motion. However, the prolonged healing period and the necessity for meticulous wound care limit its practicality, especially in larger defects.”

Study Methodology

The comprehensive literature review, adhering to PRISMA guidelines, analyzed articles published from 1965 to 2024. PubMed, Embase, Cochrane Register, and other databases were searched for relevant studies. Case reports and non-surgical intervention studies were excluded. Quality assessments utilized the Newcastle-Ottawa Scale, categorizing studies as poor, fair, or good/high quality. Researchers stated data were synthesized using multi-intervention network meta-analysis and direct head-to-head comparisons to evaluate recurrence and postoperative complications.

Recurrence Rates

The analysis found secondary closure techniques, specifically local/distant flaps and split-thickness skin grafts, significantly reduced recurrence rates compared to primary closure. Researchers reported local/distant flaps reduced recurrence by 55%, while split-thickness skin grafts achieved a 45% reduction. In contrast, primary closure showed the highest recurrence rates, likely due to its inability to address extensive tissue damage and persistent inflammation. Secondary intention healing offered only modest improvements in recurrence but avoided donor site morbidity.

Complications

• Wound dehiscence: Primary closure and secondary intention healing showed lower risks compared to flap procedures.
• Infections and bleeding: No significant differences were observed across closure methods.
• Movement impairments: Insufficient data limited robust conclusions.

Additional Considerations

Researchers stated that flap procedures demonstrated superior integration with surrounding tissue and long-term outcomes. However, their complexity increases the risk of complications like tissue necrosis and hemorrhage. Split-thickness grafts provide effective coverage but may lead to donor site morbidity, according to the analysis. Secondary intention healing avoids these issues but requires extended healing time and intensive wound care. 

Limitations

As far as limitations of the analysis, researchers noted that most included studies were retrospective, introducing potential bias. They also stated that variability in patient populations and follow-up periods contributed to study heterogeneity. Finally, a lack of standardized recurrence definitions limited comparability across studies.

To improve outcomes, researchers suggested preoperative anti-inflammatory therapies, such as biologics or short courses of corticosteroids, are recommended to delineate inflamed from healthy tissue, facilitating surgical precision.

Conclusion

For patients undergoing wide excision for HS, researchers found that secondary closure techniques, particularly local/distant flaps, should be considered the gold standard for minimizing recurrence. While primary closure remains a practical option, they noted it is associated with higher recurrence rates and limited suitability for extensive defects. Flaps and grafts offer robust solutions but require careful patient selection and surgical expertise. Researchers suggested that future research should focus on multicenter, randomized trials to refine these findings and establish evidence-based guidelines for wound closure in HS management.

References

1. Rompel R, Petres J. Long-term results of wide surgical excision in 106 patients with hidradenitis suppurativa. Dermatol Surg. 2000;26(7):638-643. doi:10.1046/j.1524-4725.2000.00043.x
2. Cucu CI, Ciobotariu I, Paradisi A, et al. Wound closure techniques after wide excision for hidradenitis suppurativa: a systematic review and meta-analysis. Int J Dermatol. Published online November 14, 2024. doi:10.1111/ijd.17553