Surgical Treatment of Acne Inversa at the University of Heidelberg

Surgical Treatment of Acne Inversa at the University of Heidelberg

coloproctology
© Urban & Vogel 2000
Surgical Treatment of Acne Inversa at the
University of Heidelberg
Hjalmar Kurzen, Sabine Schönfelder-Funcke, Wolfgang Hartschuh 1
Abstract
Acne inversa is a chronic, recurrent, fistula- and abscess-forming disease formerly
called hidradenitis suppurativa, pyodermia fistulans sinifica or acne tetrade. Like in
acne vulgaris, the main pathogenetic mechanism consists of follicular occlusion with
subsequent inflammation of the pilosebaceous unit. The aim of this study was to
determine the outcome of the surgical procedure and wound management applied in
our clinic, to identify pathogenetic factors contributing to the course of the disease
and to evaluate acne inversa patients with special respect to clinical manifestations,
histology and bacterial colonisation.
We evaluated 66 patients with acne inversa, treated in our clinic between 1987
and 1999. Radical excision combined with open wound healing was performed in all
patients.
We found both sexes equally frequent, mean age at disease onset was 22.5 years,
mean age at presentation was 34.7 years, mean duration of disease was 11 years. 55%
of patients also had a family history of acne inversa. 80% of patients were smokers.
80% of males suffered also from pilonidal sinus compared to 57% of females, while
only 45% of males had inguinal or perianal lesions compared to 90% of females.
There was no correlation of disease activity or prevalence with other diseases,
especially not with atopic dermatitis, Crohn’s disease or colitis ulcerosa.
Histologically most patients showed follicular occlusion, fibrosing granulomatous
dermatitis and formation of sinus tracts lined by pathologically differentiated
epithelia. Staphylococcus aureus was frequently found pre-operatively. Minor
recurrent disease on operated sites was noted in 23% of patients, but only 5.75% of
patients required further surgical intervention. Over 90% of patients were satisfied
with functional and esthetical result.
Since the inflammatory process clearly emerges from the pilosebaceous unit, the
aim of surgical treatment has to be the elimination of hair follicle bearing skin from
the affected intertriginous areas. Radical excision combined with subsequent open
wound healing has proven to be a reliable treatment resulting in minimal recurrent
disease and satisfactory cosmetic result.
Key Words: Acne . Hidradenitis . Smoking . Obesity . Treatment . Recurrent disease .
Esthetical result
1
Department of Dermatology, University of Heidelberg.
Presented at the European Council of Coloproctology, October 30 – November 2, 1999 in Munich.
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coloproctology 22 · 2000 · Nr. 2 © Urban & Vogel
Kurzen H, et al. Surgical Treatment of Acne Inversa
Chirurgische Behandlung der Acne inversa an der Universität
Heidelberg
Zusammenfassung:
Acne inversa ist eine chronisch rezidivierend verlaufende, entzündliche Erkrankung
der intertriginösen, terminalen Haarfollikel, die früher auch unter den Namen
Hidradenitis suppurativa, Pyodermia fistulans sinifica oder Acne tetrade bekannt
war. Wie bei der Acne vulgaris besteht der pathogenetische Mechanismus in einer
Verstopfung des Haarfollikelostiums mit nachfolgender Ruptur des Follikels. Dies
führt zu einer chronischen granulomatösen Entzündung, welche durch Superinfektionen, Abszess- und Fistelbildung kompliziert wird. In dieser Studie wurden
Krankheitsverlauf, Histologie, bakterielle Besiedelung und das Ergebnis der
durchgeführten Operationen und Wundbehandlungen beurteilt.
Hierzu untersuchten wir 66 Patienten mit Acne inversa, die zwischen 1987 und
1999 in unserer Klinik behandelt worden waren. Bei allen Patienten wurden die
befallenen Hautareale radikal exzidiert. Die Wundheilung erfolgte sekundär.
Wir fanden die Krankheit bei beiden Geschlechtern gleich häufig, das mittlere
Erkrankungsalter war 22,5 Jahre bei Krankheitsbeginn und 34,7 Jahre bei Vorstellung
in unserer Klinik. Die mittlere Krankheitsdauer war elf Jahre. Mehr als die Hälfte der
Patienten hatten eine positive Familienanamnese. 80% der Patienten waren Raucher.
80% der männlichen Patienten litten auch unter einem Pilonidalsinus im Gegensatz
zu 57% der Frauen. Nur 45% der männlichen Patienten hatten einen Befall der
Inguinal- oder Perianalregion im Gegensatz zu 90% der Frauen. Es bestand keine
Korrelation der Krankheitsaktivität mit Hauttyp, Adipositas oder anderen
Krankheiten, insbesondere nicht mit der atopischen Dermatitis, dem Morbus Crohn
oder der Colitis ulcerosa. Histologisch ließen sich bei allen Patienten Zeichen der
follikulären Okklusion und einer fibrosierenden granulomatösen Dermatitis
nachweisen. Darüber hinaus zeigten sich in der überwiegenden Zahl der Fälle
abszedierende Fistelgänge, welche mit unterschiedlich verhornten und stark
entzündlich alterierten pathologischen Epitheltypen ausgekleidet waren. Präoperativ
konnte in den meisten Fällen eine Besiedelung mit Staphylococcus aureus
nachgewiesen werden. Geringfügige Rezidive entstanden in 23% der Fälle, jedoch
mussten nur 5,75% der Patienten ein zweites Mal operiert werden. Über 90% der
Patienten waren mit dem ästhetischen und funktionellen Ergebnis der Behandlung
zufrieden.
Da der entzündliche Prozess von den terminalen Haarfollikeln der
intertriginösen Areale ausgeht, muß es das Ziel der chirurgischen Therapie sein, diese
zu entfernen. Die radikale Exzision kombiniert mit offener Wundheilung ist eine
zuverlässige Behandlungsstrategie, welche nur in geringfügigem Ausmaß zu
Rezidiven führt und deren kosmetisches und funktionelles Ergebnis
zufriedenstellend ist.
Schlüsselwörter: Akne . Hidradenitis . Rauchen . Adipositas . Behandlungsstrategie .
Rezidiv . Kosmetisches Ergebnis
coloproctology 22 · 2000 · Nr. 2 © Urban & Vogel
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Kurzen H, et al. Surgical Treatment of Acne Inversa
Figure 1a. Fifty-three-yearold female patient with
30-year history of of acne
inversa. Apart from the
complete inguinal, perineal
and perianal area as shown
above, this patient is also
affected in the axillary
areas.
Figure 1b. Situs after
surgery: The affected area
was radically excised in
general anesthesia. If
smaller skin areas have to
be excised, local anesthesia
using the subcutaneous
infiltration method can be
used.
Figure 1c. After 2 weeks
healthy granulation tissue is
formed from the wound
ground. In this phase of the
healing process, it is
important to regularly
extend the wound edges in
order to prevent them from
joining prematurely, a major
cause of recurrent disease
and of scar contraction.
Figure 1d. The esthetical and
functional result after 4
months. Hairless, smooth,
scar tissue without any sign
of inflammation.
Acne inversa, formerly known under the names of
hidradenitis suppurativa, pyodermia fistulans sinifica,
Verneuil’s disease or acne tetrade, is like acne vulgaris
believed to be caused by follicular occlusion with
subsequent rupture and inflammation of the
pilosebaceous unit in the intertriginous areas. This leads
to vast, periodically inflamed lesions, that are undermined by a system of fistulas and draining sinuses [2, 4].
Since the pathogenesis and treatment of the disease is
still a matter of debate, we aimed at identifying
pathogenetic factors contributing to the course of the
disease. The outcome of the surgical procedure and
wound management applied in our clinic was
determined and clinical manifestations, histology and
bacterial colonisation were evaluated.
78
Patients and Method
To pursue these goals, we analyzed patients with acne
inversa treated in our clinic between 1987 and 1999.
Thirty-four patients, treated between 1987 and 1996
were personally re-examined and 32 patients treated
between 1997 and 1999 were interviewed by
questionnaire.
Radical excision of affected skin areas combined
with open wound healing was performed in all
patients. If only smaller areas were affected, local
anesthesia was used, since 1998 also the subcutaneous
infiltration method. In extended cases, general
anesthesia was applied. Sitz-baths were performed,
coloproctology 22 · 2000 · Nr. 2 © Urban & Vogel
Kurzen H, et al. Surgical Treatment of Acne Inversa
Figure 2. Histological section of a draining
sinus from perianal acne inversa.
Hematoxilin/eosin-staining. Note the free
hair shafts in sinus lumen, penetrating into
the surrounding tissue. The sinus is lined by
a pathologically differentiated epithelium,
clearly different from normal epidermis.
wound edges were extended and ointment dressings
were changed twice daily (Figures 1a to 1d).
Results
We found both sexes equally frequent. 55% of patients
had a positive family history of acne inversa. The mean
age at disease onset was 22.5 years. The mean age at
presentation was 34.7 years, leading to a mean duration
of the disease of 11 to 12 years.
73% of patients were smokers and 7% were exsmokers. In the normal population of Germany, only
about 30% are smoking. There was no correlation of
disease activity or prevalence with other diseases,
especially not with atopic dermatitis or inflammatory
bowel diseases.
The mean hospital stay was 26 days between 1987
and 1996. It could be reduced to 11.3 days between 1997
and 1999. This is mostly due to better training of staff
and patients. The mean wound healing time is on
average 3 months, depending of course on the extension
of the excised skin areas.
Recurrent disease was noted in 23% of patients,
emanating in most cases from the wound edges in
the first postoperative months. It could mostly be
treated by intensified local wound care and
coloproctology 22 · 2000 · Nr. 2 © Urban & Vogel
antibiotics. Only 5.75% of patients needed further
surgical treatment.
Of those patients with recurrent disease, 84% were
smokers and 16% ex-smokers. There was no nonsmoking patient with recurrent disease. Of those
patients with new manifestation of acne inversa on
other body sites, there were 80% smoker and 20% exsmoker. Non-smokers did not develop new lesions.
Looking at body weight as potential aggravating
factor, we found that only 5% of patients with recurrent
disease had normal body weight, as indicated by the
body mass index. 63% of patients with recurrent
disease were more than 10% overweight. Of the
patients who developed new lesions, 16% had normal
weight and 25% were obese. 78% of the disease free
patients were normal weight and 12% were obese. All
obese patients were also smoker.
Regarding the distribution of acne inversa lesions,
we found that 80% of males also suffered from
pilonidal sinus compared to only 57% of females. On
the other hand only 45% of males developed inguinal
or perianal lesions compared 90% of females. The
axillary area was affected equally frequent in males and
females.
Histologically we found in all cases signs of
follicular occlusion and, depending on the age of the
lesions examined, fibrosing granulomatous dermatitis
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Kurzen H, et al. Surgical Treatment of Acne Inversa
and formation of sinus tracts lined by pathologically
differentiated epithelia [3]. Frequently free hair shafts
could be demonstrated in the sinus and the inflamed
dermis (Figure 2). Pre-operatively a mixed bacterial
colonisation was found. Staphylococcus aureus could
frequently be demonstrated.
95% of our patients operated between 1987 and
1996 were satisfied with the functional and esthetical
result of the treatment. The same holds true for overall
satisfaction. Those patients who were operated in the
last 2 years were less satisfied. Only 68.5% approved of
the esthetical and functional result and overall
satisfaction was reduced to 77%. This result can be
explained by and correlates with the shortened
hospitalization time mentioned before, and the shorter
postoperative period in the second group. Scars still
change in structure and color for up to 2 years
postoperatively. Points of criticism were scar color,
structure and extension.
References
1.
2.
3.
4.
Endo Y, Tamura A, Ishikawa O, et al. Perianal hidradenitis
suppurativa: early treatment gives good results in chronic or
recurrent cases. Br J Dermatol, 1998;139:906–10
Hartschuh W. Acne inversa. Coloproctology, 1997; 19: 9–13
Kurzen H, Jung EG, Hartschuh W, et al. Forms of epithelial
differentiation of draining sinus in acne inversa. Br J Dermatol
1999; 141: 231–9
Küster W, Rödder-Wehrmann O, Plewig G. Acne inversa.
Pathogenese und Genetik. Hautarzt 1991; 42: 2–4
Address for Correspondence:
Dr. Hjalmar Kurzen, Department of Dermatology, University
of Heidelberg, Voßstraße 2, D-69115 Heidelberg, Germany,
Phone (+49/6221) 568505, Fax 565977,
e-mail: Hjalmar_Kurzen@med.uni-heidelberg.de
Discussion
In conclusion, we found that the majority of acne
inversa patients are smokers. Obesity has to be
considered a trigger factor, leading to a more severe
course of the disease and increasing the risk for
recurrent disease. Recurrent disease is like the primary
disease extremely rare in normal weight and nonsmoking patients, therefore patients should be
encouraged to stop smoking and normalize their
weight.
Mean hospitalization time could be reduced to
approximately 11 days, without worsening of treatment
success, but at the cost of higher personal involvement
and inconvenience of the patients.
Since the inflammatory process clearly emerges
from the pilosebaceous unit, the aim of surgical
treatment has to be the elimination of hair follicle
bearing skin from the affected intertriginous areas.
Radical excision combined with subsequent open
wound healing has proven to be a reliable treatment
resulting in minimal recurrent disease and satisfactory
cosmetic result. In order to shorten wound healing time,
mesh-grafting can be considered [1], especially in very
extended cases. The cosmetic result, however, is not as
favourable as with open wound healing.
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coloproctology 22 · 2000 · Nr. 2 © Urban & Vogel