I. Introduction

While it is more appropriate for some procedures to be performed under general anesthesia, there are a number of procedures that can be done at the doctor’s office. This chapter covers HS treatment procedures that can be performed in the office.

II. Botulinum Toxin Injections

Botulinum toxin is in a class of medicines called neurotoxins. This class now includes brands like Botox®, Myobloc®, Dysport®, Jeuveau®, and others. These medications are injected through the skin. Botulinum toxin injections work by putting up a temporary wall between our muscles and the nerve signals we use to move them, which temporarily paralyzes the muscles. Our bodies break down the walls over time, which means injections need to be done repeatedly to maintain the effect. These medicines are traditionally used to reduce wrinkles that form during facial muscle movement and also used for migraine headaches.

As our scientific knowledge advances, doctors are finding new ways to use neurotoxin to treat various diseases, including HS. Botulinum toxin injections were first used to help HS patients by reducing the amount of sweating in areas affected by HS. It was found that pain and irritation from HS decreased and the effect lasted about 10 months. Use of these injections in people with HS, with disease severity ranging from mild to severe (Hurley I to Hurley III), has since been reported several times, but with varying effect. The doses have varied as well.

It is generally considered something that may work for some patients with HS but not necessarily for others, but will not make HS symptoms worse. The brand name of the botulinum toxin does not seem to affect results. The injections are pin-pricks and the medicine itself does not sting or burn. However, as botulinum toxin injections for HS may not be covered by insurance plans, it can be expensive.

• Botulinum Toxin Injections: Patient Selection.

People with mild HS (Hurley I) are the most appropriate candidates.

• Botulinum Toxin Injections: Post-operative Care.

No post-operative care is required.

III. Chemical Peels

Chemical peeling involves using liquids like trichloroacetic acid, glycolic acid, and resorcinol to strip off the superficial skin layers in a controlled
fashion, allowing the skin to heal in a better way. Chemical peeling is most often used to rejuvenate sun-damaged skin. It can also help reduce pre-cancerous spots.

Topical resorcinol has been studied in patients with HS and found to be beneficial. Please note that it is currently only available from specialty compounding pharmacies in the United States, so your doctor would need to find a specialty pharmacy that is able to make the resorcinol cream or ointment in order for you to access the medication. Please see Chapter 16 for further information.

• Chemical Peels: Patient Selection.

Anyone with HS may benefit from topical resorcinol. However, it is likely that people with mild (Stage I) or moderate (early Stage II) disease will benefit most.

• Chemical Peels: Post-operative Care.

No postoperative care is required.

IV. Cryoinsufflation

This technique was originally intended for people with HS lesions that would benefit from a systemic treatment but who could not tolerate or did not want systemic therapy (for example, pregnant women). Liquid nitrogen is used to treat HS sinus tracts/tunnels. Liquid nitrogen is a gas that dermatologists often use to treat warts and other lesions. It is very cold at -190 degrees Celsius. Skin cells are easily damaged at this low temperature. A special attachment with a thin tube or needle on one end is placed on a liquid nitrogen spray bottle. The area to be treated is numbed with lidocaine, and the thin tube/needle is placed into the opening of an HS tunnel. The liquid nitrogen is then sprayed into the tunnel in short bursts. The gas expands through the entire tunnel and any interconnected tunnels before passing out distant tunnel openings. The extreme cold causes injury to the lining of the tunnels, hopefully resulting in tunnel closure when healed. Each tunnel usually requires at least two treatment sessions. Potential side effects include pain, formation of ulcers, or rarely, air embolism.

In the authors’ experience, this procedure has worked well in areas with around 1-3 tunnels.

• Cryoinsufflation: Patient Selection.

People with any stage of HS are possible candidates.

• Cryoinsufflation: Post-operative Care.

The treated sites are bandaged. Any pain afterwards can be treated with acetaminophen/paracetamol (Tylenol®) or other pain medications if needed and the occasional ice pack.

V. Incision and Drainage

This procedure is used for swollen and tender bumps in the skin called boils or abscesses. These generally contain pus, and the best treatment is to release the pus. The boil is numbed with a lidocaine injection, and a sharp scalpel or punch tool (a small round cookie-cutter like instrument, typically measuring 3 to 4 millimeters in diameter) is used to make an opening in the top of the boil. Pressure is used to push the pus out of the boil. Sometimes, the inside of the boil is rinsed with water to clean the area and a packing made of cotton string gauze is placed inside the wound. The packing can be removed the next day, and the area cleaned and re-bandaged.

• Incision and Drainage: Patient Selection.

People with any stage of HS are possible candidates.

• Incision and Drainage: Post-operative Care.

The treated sites are bandaged. Any pain afterwards can be treated with acetaminophen/ paracetamol (Tylenol®) or other pain medications if needed and the occasional ice pack.

VI. Intralesional Steroid Injection

Steroids are medicines that have a great deal of effect against inflammation and can act like a blanket on a fire, putting out the flames and bringing sometimes significant relief within hours. Your healthcare provider can inject a steroid solution (typically called triamcinolone or Kenalog® solution) directly into inflamed HS bumps to decrease inflammation and pain.

• Intralesional Steroid Injection: Patient Selection.

People with any stage of HS are possible candidates.

• Intralesional Steroid Injection: Post-operative Care.

There is no specific care needed after this procedure.

VII. Deroofing and Surgical Excisions

Please see Chapter 21 for information regarding deroofing. Information on surgical excisions can be found in Chapter 21 and Chapter 22.

VIII. Staged Carbon Dioxide (CO2) Laser Marsupialization

This procedure was developed based on the knowledge that HS is a disease of the skin and is not found in fat or muscle. Knowing the bounds of the disease helps the surgeon remove as much of the disease as possible without taking healthy skin.

The light wavelength put out by a carbon dioxide (CO2) laser is absorbed by water. It can penetrate no deeper than the skin. It also helps reduce bleeding by sealing off blood vessels as it cuts through the tissue. The surgeon defines the area by touch and maps out the borders of the disease in the involved area, then uses the CO2 laser to cut around that border.

The active HS lesions are removed off the underlying healthy tissue with the laser. Care is taken so that no HS-affected skin remains at the base. Once the HS affected area is removed, a metal probe is used to explore the borders looking for hidden tunnels. If any are found, they are also removed. The area is then bandaged and allowed to heal by itself (secondary intention healing). Healing can take up to three months, but patients can typically still function during the healing period with little/manageable pain, and patients are encouraged to go about their daily lives. The chances of HS coming back in the area remain extremely low, and the resulting scars are generally much preferred to the HS-involved skin that was removed. This procedure can be done under local anesthesia in the office or under general anesthesia at a surgery center.

• CO2 Laser Marsupialization: Patient Selection.

People with any stage of HS are candidates.

• CO2 Laser Marsupialization: Post-operative Care.

Care after the surgery involves petrolatum (Vaseline®) ointment, non-stick pads, gauze, and tape applied to the area and changed daily. The areas gradually become smaller as they heal. Healing generally takes about 3 months even for large areas. However, in some cases, longer healing time is needed.