Answer:
Hidradenitis suppurativa, an inflammatory disease of the apocrine glands, presents most frequently as deep recurrent abscesses in the axillae, which may result in scarred deep sinus tracts, fluctuant draining of abscesses, and excruciating pain with limitation of abduction of the shoulder. Although seen most commonly in young females in the axillae, it also occurs in the groin and perineum and in the areolae. Early acute cases can be treated with local therapy, such as incision and drainage of the abscess, followed by control with long-term antibiotic therapy. However, once the disease entity is established with deep scarring and sinus tracts, the only appropriate therapy is surgical excision of the involved area. These patients are too frequently not offered the alternative of operative management of this disease until an unpleasant, prolonged course of conservative treatment for abscesses and pain has been undertaken. Rarely must patients be convinced of the need for operative interventions, as they have usually suffered extensively with the discomfort and unpleasantness of this disease. Culture of the purulent discharge and appropriate antibiotic therapy for a period of at least 10 days before operative intervention are important.
Excision of all of the involved tissue is the ultimate goal of the operative procedure. Primary closure can be accomplished with large defects, but the surgeon must not compromise the excision to accomplish primary closure. Large areas of involvement (8 x 15 cm) can be excised and closed primarily if the wound is closed with heavy retention sutures to approximate the axillary fascia and subcutaneous tissues and if careful subcuticular skin closure is accomplished. When primary closure is not feasible, split-thickness skin grafts and immobilization of the arm with Velpeau’s dressings comprise the next choice. We have not found it necessary to use any type of skin flap to accomplish skin coverage in the axillary vault after excision of hidradenitis suppurativa. Good results have also been reported with excision without closure, allowing the wound to heal by secondary intention.
When the disease has extended beyond the axilla onto the chest wall or the upper arm, it is preferable to excise the involved areas entirely and apply split-thickness skin grafts. It has been our practice to undertake the excision and grafting on one axilla at a time so that the patient is not totally disabled during the healing period. When the surgeon can clearly excise and close the wounds primarily, it is feasible to undertake correction of the disease in both axillae with one operative procedure. Good healing and lack of wound infection are usual when all the diseased tissue is properly excised. If the scarred sinuses or involved glands are not completely excised, delayed wound healing and infection are common. Because these patients have had limited abduction of the shoulder for long periods before the operative intervention, the need for exercises to abduct the arm must be stressed and the patients followed until full abduction is accomplished.