Hidradenitis Suppurativa: A Guide to Surgical Management with Omega3-rich Fish Skin Grafts

September - October 2022

Hidradenitis Suppurativa: A Guide to Surgical Management With Omega3-Rich Fish Skin Grafts Editorial Summary

Hidradenitis suppurativa (HS) is a chronic inflammatory disease that manifests with abscesses and sinuses formations. Treatment of advanced and chronic HS includes surgical resection and skin reconstruction that is often challenging because the remaining tissue is at a poor healing stage, and lack of vascularization.

Introduction

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Dr Michael S. Romberg CEO, SAS Surgical Ltd.

idradenitis suppurativa (HS) is a chronic inflammatory skin condition affecting apocrine gland bearing skin in the axilllae, groin and under the breasts. It is characterised by persistent or recurrent nodules and abscesses that culminate in a purulent discharge, sinuses and scarring. Often presenting between the ages of 20 and 40, it is much more common in females and also affects individuals with a family history of this condition, smokers, patients with other inflammatory conditions such as inflammatory bowel disease, obese individuals with insulin resistance; and as a result of some medication side effects, such as lithium and biologics. It is thought to be an auto-inflammatory syndrome and can affect multiple areas anatomically including the inner thighs, as well as anogenital involvement, most commonly the scrotum perineum vulva and the perianal folds. The typical presentation is open headed comedones, with some tender papules, and nodules; in addition pustules pseudocysts and abscesses may also be present. If left untreated, the condition can progress onto hypertrophic scarring as well as sinuses. There are a number of subtypes of HS, which include scarring folliculitis, a frictional furuncle, and syndromic HS. The severity of HS is assessed using the Hurley grading system, which is an assessment tool comprising of three clinical stages.

Mokena IL, United States

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Wound Masterclass - Vol 1 - September 2022

Hurley Grading System •

Stage one is a solitary or a multiple isolated abscess formation without sinus tract stage

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Stage two involves recurrent abscessing with single or multiple wide spaced lesions

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Stage three involves diffuse involvement of a anatomical area with multiple connected sinus tract and abscesses

HS can progress onto several serious complications which include superseding infection, lymphoedema, anaemia of chronic disease, and skin cancer (Squamous cell carcinoma, particularly in male anogenital HS).

A common occurrence in HS is the delay to diagnosis, which can be due to a number of factors: typically a triad of symptoms needs to be present for this diagnosis to be made; these include the presence and recurrence of lesions, specific anatomical distribution, and the characteristics of these lesions. It is important to bear in mind the differential diagnosis, which may be inflammatory bowel disease, and other types of cystic lesions.

The quality of tissues in chronic and longstanding HS is poor, which is an added reconstructive challenge for the wound care clinician.

Fish skin grafts are a unique biologic scaffold resembling the dermal extracellular matrix, promoting cellular ingrowth and neovascularization. FSG also contains Omega3, which is anti-inflammatory. We hypothesize that FSG can be used as part of the surgical intervention for HS, both as wound bed preparation and closure support, that results in faster and better healing.

Hidradenitis Suppurativa: A Guide to Surgical Management With Omega3-Rich Fish Skin Grafts

Methods A case series was conducted with 9 HS patients who received treatment with FSG at SAS Surgical LTD, performed by Dr. Michael Romberg. HS defects varied from the axilla, groin, labia and abdominal wall.

Patients received excision of the damaged tissues, followed by application of FSG to the wounds until they were ready for secondary closure or split thickness skin graft (STSG).

Figure 1: A representative case of reconstruction of axilla HS using fish skin graft. 1a: Severe HS with skin pulling lesion. 1b: Post-excision lesion.

1c: Application of FSG. 1d: Granulated woaund bed after 5 days. 1e: Wound bed is ready for STSG. 1f: Full STSG take.

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Conclusion

Results

The management of HS is a multi-staged procedure, with or without STSG, and often faces a high risk of recurrence rates due to infection and patient comorbidities. Omega3 fish skin supports the preparation of the wound bed for early and successful grafting, or secondary closure. FSG is an effective alternative to conventional surgical interventions of HS that helps shorten hospital stays. The use of FSG is safe, involves no complications and results in rapid healing.

Complete healing was achieved in all cases without complications. FSG resulted in faster granulated tissues that led to successful closure or effective STSG after 1 - 3 months. Patients also noticed scar reduction, better cosmetic outcomes, and less pain.

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