Pre-Operative Ultrasound Improves Surgical Margin, May Lower Recurrence in Patients With Hidradenitis Suppurativa

The use of ultrasound prior to surgery to assess severity of hidradenitis suppurativa (HS) can improve surgical margin delimitation and may lower disease recurrence rates at 24 weeks in patients with the chronic inflammatory skin disease, according to study data published in the Journal of the European Academy of Dermatology and Venereology.

Obesity, male sex, Hurley II stage, and increased International Hidradenitis Suppurativa Severity Score System 4 (IHS4) scores increase the risk for inaccurate clinical surgical delimitation, the study adds.

Patients in the study had moderate to severe HS with draining subcutaneous tunnels and minimal-to-nonexistent inflammatory activity for ≥24 weeks. All patients were considered candidates for surgical treatment with excision and secondary wound closure, or healing by secondary intention. Patients were only included if their projected skin excised area after clinical examination was ≥15 cm².

Before to each surgical procedure in the ultrasound surgical delimitation cohort (n=20), a dermatologist performed the delimitation of projected skin excised area in the operating room. Skin excised area was determined by clinical examination and ultrasound. In a clinical surgical delimitation cohort (n=20), only clinical examination determined the skin excised area. The outcomes of interest for this study included the clinical and ultrasound projected skin excised area and surgical recurrence.

Ultrasound surgical margin delimitation prior to operation increased the mean excised area by 3.67 cm, from 22.62 cm² after clinical examination to 26.29 cm² after ultrasonography (P =.004). Pre-operative ultrasonography increased the projected skin excised area in 65% of surgical procedures, according to a Bland Altman plot.

Factors associated with an increased difference between clinical and ultrasound surgical delimitation included higher IHS4 scores (0.42; P =.004), body mass index (0.28; P =.02), male sex (1.30; P =.08), and Hurley stage II vs III (6.10; P =.003). Although the recurrence rate at 24 weeks was higher in the surgical clinical delimitation cohort was (30%) vs the in preoperative ultrasonography cohort (10%), this difference was not statistically significant (P =.10).

Limitations of the study included its small sample size, the use of only 1 type of surgical procedure, and the limited follow-up duration.

In regard to patients who are obese, men, or have Hurley stage II, the researchers added that “special attention should be given to these patients when surgical delimitation is based only on clinical examination.”

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Reference

Cuenca-Barrales C, Salvador-Rodríguez L, Arias-Santiago S, Molina-Leyva A. Pre-operative ultrasound planning in the surgical management of patients with hidradenitis suppurativa [published online April 8, 2020]. J Eur Acad Dermatol Venereol. doi: 10.1111/jdv.16435