NEW YORK — In the past few years, the list of highly targeted systemic anti-inflammatory treatments effective for hidradenitis suppurativa (HS) activity has grown substantially, but surgery should still be considered an option to accelerate resolution of highly symptomatic lesions, according to an expert.

“Surgery has traditionally been considered a treatment of last resort, but I think this has completely changed,” said Amit Garg, MD, professor and founding chair of the Department of Dermatology at the Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.

Because of the unpredictable response to any given targeted therapy now available for HS, patients might wait months during multiple treatment trials for troublesome lesions to resolve, creating a role for surgical intervention in selected patients, Garg explained. He suggested that surgery is attractive when severe lesions are a major source of morbidity and diminished quality of life.

Despite More Therapies, HS Resolution Can Be Slow

Although the recent expansion of therapeutic options for HS has been welcomed, Garg noted that patients cannot always rely on benefit from any single therapy. This can be traced to the heterogeneity of the drivers of disease expression.

“I think it is unlikely that HS will ever be controlled with a single therapy,” Garg said at the annual Atlantic Derm Conference (ADC).

Current efforts to identify phenotypes or biomarkers that will guide therapy may eventually help to better individualize management, but Garg considers surgery a practical option for draining lesions that might take months to resolve even after an effective therapy is initiated.

Surgery might be even more attractive if offered on an outpatient basis, according to Garg, noting that this approach not only circumvents the cost of hospitalization but also permits patients to return more quickly to activities of daily living.

Data to support an outpatient approach was presented at the ADC. Although this work was not the focus of Garg’s presentation, he was a senior author of a poster presented by his resident, Jared S. Kahn, MD. The poster documented a series of seven patients with Hurley stage III HS treated with a carbon dioxide laser. The retrospective review provided a proof of principle for an approach Garg said he hopes to see tested in prospective trials.

For the 11 lesions treated on an outpatient basis in the seven patients in this series, the primary outcome was complete re-epithelialization without postoperative drainage or an open sinus. All patients, ranging in age from 17 to 64 years, underwent excision with a CO₂ laser followed by marsupialization.

“Recurrence was uncommon. Most treated anatomical fields demonstrated no active disease at follow-up, but mild recurrences occurred at a minority of sites,” Kahn reported in the poster.

With the longest follow-up extending to 10 months, the time to healing ranged from 3 to 6 months. There were no intraoperative complications and no hospital admissions. Postoperative recovery was generally uneventful.

“Minimal postoperative pain was recorded in all of the evaluable cases. Most entries documented pain scores of zero,” Kahn reported.

Office-Based Surgery for HS Is Well Tolerated

While there were no major postoperative complications, functional deficits, or wound-related adverse events, there was one case of substantial positional discomfort post-operatively. It was determined to be related to impaired shoulder movement, and it subsequently resolved.

Of the lesions treated, eight of the 11 involved the right or left axilla. One procedure was performed on a lesion on the thigh. Treatment of the only female patient in this series involved both right and left inframammary lesions. 

There were no recurrences in eight of the 11 lesions. There was a mild recurrence in one of the inframammary lesions and mild recurrences in two axilla lesions. These latter recurrences were recorded in the 17-year-old male patient with shoulder pain.

This series does not represent the first report of outpatient surgery for HS. In a 2020 focused review of published studies that involved either lesion unroofing or excision, data were drawn from 3914 patients in 55 articles. These reports included an array of surgical interventions, but all were office-based.

The rate of recurrence was 50% lower with unroofing than excision (14.5% vs 30%; P = .015), and the rate of complications was lower (12% vs 26%; P < .001). The analysis suggested without that continuation of medical therapy through the course of postoperative recovery “may be” associated with lower recurrence rates.

Even if this report did support a role for outpatient surgery HS, the rate of recurrence was much higher than that reported in the far smaller seven-patient experience presented at the ADC meeting. Like the data presented by Kahn, many studies were small and retrospective. Only 11 (20%) were prospective, and many were published 10 or more years ago.

Given the already common delays in the diagnosis of HS, Garg emphasized the urgency of providing symptomatic relief in patients first seen with advanced draining lesions. While early surgery has not routinely been considered in these patients, it might often be warranted, he added.

“The burden of this disease can be very substantial,” he said. He cautioned that the increasing options for pharmacologic control of HS do not always rapidly result in a level of disease control that meaningfully improves quality of life.

Garg reported having financial relationships with AbbVie, Almirall, Bluefin Biomedicine, Boehringer Ingelheim, Immunitas Therapeutics, Incyte, Insmed, Navigator, Novartis, Oruka, Otsuka, Pfizer, Priovant, Sun Pharma, Takeda, UCB, and Zura Bio. Kahn reported having no potential conflicts of interest.