Download Scanner-assisted carbon dioxide laser surgery: A

LASER
SURGERY
Scanner-assisted carbon dioxide laser surgery: A
retrospective follow-up study of patients with
hidradenitis suppurativa
Jan Lapins, MD, Karin Sartorius, MD, and Lennart Emtestam, MD
Stockholm, Sweden
Background: The chronic fistulating lesions of hidradenitis suppurativa spread by contiguous growth, and
all affected tissue needs to be surgically removed.
Objective: The aim of our study was to evaluate a surgical method for treatment of Hurley stage II
hidradenitis suppurativa (HS), the carbon dioxide laser rapid-beam optomechanical scanner system in
continuous mode.
Methods: Thirty-four patients were evaluated after treatment; 31 patients were women, and the mean age
was 33.9 years (range, 15-55 years). All patients had had HS for a mean of 13.4 years (range 1-35 years) and
more than 3 recurrences of suppurating lesions in the year before inclusion in the study. All lesions had
been classified as Hurley stage II. The mean follow-up time after carbon dioxide laser surgery was 34.5
months (range, 7-87 months), and patients were later contacted by telephone about recurrences and the
end results.
Results: The mean healing time was about 4 weeks (range, 3-5 weeks). During follow-up, 4 of the 34
patients had recurrences at the surgical site, that is, locoregional HS. Thirty had no recurrences in the treated
area, but in 12 cases de novo suppurating lesions, separated from the initial surgical site by ⬎5 cm,
developed. Twenty-five patients had flares of HS lesion(s) in an area other than the treated site. Eight had
no recurrences.
Conclusion: Macroscopically controlled tissue-selective carbon dioxide laser treatment of HS is a fast,
efficient treatment and well accepted by the patients. (J Am Acad Dermatol 2002;47:280-5.)
H
idradenitis suppurativa (HS) (also called
acne inversa) is a cicatrizing and frequently
persistent inflammation of the terminal hair
follicles of apocrine gland– bearing areas in adults.1,2
One or both axillae and the inguinal region may be
affected, often with spread to the scrotum, labia,
mons pubis, mammary or perineal region, and buttocks. This condition may remain relatively mild, but
it is nevertheless distressing,3 ranging from a few but
recalcitrant suppurating lesions to an advanced,
widespread, and disabling disease lasting for years
or decades. In long-standing cases HS can be comFrom the Karolinska Institutet, Department of Medicine, Section of
Dermatology and Venereology, Huddinge University Hospital.
Funding sources: The Finsen Foundation and the Edvard Welander
Foundation.
Conflict of interest: None identified.
Reprint requests: Jan Lapins, MD, Karolinska Institutet, Department
of Medicine, Section of Dermatology and Venereology, Huddinge University Hospital, Stockholm, Sweden.
Copyright © 2002 by the American Academy of Dermatology, Inc.
0190-9622/2002/$35.00 ⫹ 0 16/1/124601
doi:10.1067/mjd.2002.124601
280
plicated by squamous cell cancer as a result of
chronic inflammation.4 The etiology of HS is not
clear, but genetic predisposition, bacterial infection,
and hormonal factors have been discussed.5-8
Many therapies have been used, often with limited or temporary results, including systemic or local
antibiotics,7,9,10 hormones such as estrogen, progesterone, and cyproterone acetate,11,12 corticosteroids,
and retinoids.13 Surgery is essential and should be
done as soon as possible. Wide excisions, well beyond the clinical borders of activity, are mandatory,
regardless of the location. In this article, we describe
a surgical technique for HS and the results at followup. The aim of this technique is complete radical
ablation of diseased tissue combined with preservation of healthy tissue, with the use of a carbon
dioxide laser and a miniature microprocessor-controlled flash scanner.
MATERIALS AND METHODS
The study protocol was approved by the local
ethics committee. The medical records, including
outpatient files, of 35 patients (31 females) who
J AM ACAD DERMATOL
VOLUME 47, NUMBER 2
Lapins, Sartorius, and Emtestam 281
Fig 1. A 42-year-old woman. Lesions have been delineated in ink after anesthesia before (A)
and during (B) carbon dioxide laser surgery with the optomechanical microprocessed flash
scanner on hidradenitis suppurativa lesions of axilla with (C) and (D) close-ups, respectively.
underwent surgery for HS in our department between 1993 and 2000 were analyzed retrospectively.
The diagnosis of HS was based on history and clinical presentation on the initial examination. All patients had one or more active suppurating lesions
and had had 3 to 12 recurrent episodes of abscesses
during the 12 months before examination or continuous suppurating lesions involving the axillary, inguinal, and perineal (perianal, genital, pubic) areas,
buttocks, upper thighs, or the breast in women. One
or more lesions 10 cm or less in length were selected
for treatment. All lesions were clinically classified as
Hurley stage II,14 that is, recurrent abscesses with
tract formation and cicatrization and single or multiple widely separated lesions. No patients who had
concurrent diseases with tendencies toward fistulization, such as regional enterocolitis, ulcerative colitis, or rheumatoid arthritis, were included. The
mean duration of disease was 13.4 years (range, 1-35
years). Previous therapy included injections of and
multiple courses of antibiotics (18 patients); local
incisions (n ⫽ 20), isotretinoin (n ⫽ 3); isotretinoin
and cyproterone acetate, followed by finasteride
(n ⫽ 1); excision surgery (n ⫽ 2); and excision
surgery with transplantation (n ⫽ 1). Five patients
had undergone previous successful in loco carbon
dioxide laser surgery before 1993 in our department.
The anatomic areas treated were the axillary area in
10 cases and the inguinal-gluteal-perineal area in 22
cases. In one patient, both the axillary and perineal
areas had been treated, and in another, both the
axillary and periumbilical areas had been treated.
In accord with the patient’s views, we selected for
treatment the symptomatic lesions (ie, those with
discharge, inflammation, infiltration, or suspected
abscesses). Areas that had been asymptomatic for
more than 2 years but showed signs of previous
activity (eg, scars with postinflammatory hyperpigmentation, sometimes with dry comedones) but no
current inflammation were not treated. The diseased
skin was examined macroscopically for scarring, tissue distortion and discoloration, dry or suppurating
sinuses, macrocomedones, and other superficial
signs. The examination was completed by palpating
the defects for bulky indurations and small, firm
subcutaneous nodules or fluctuating purulent tissue.
Anesthesia
The affected area was outlined with ink (Fig 1).
After the skin was cleaned with 0.05 mg/mL chlorhexidine solution, the area was anesthetized by injection of lidocaine, 0.5 to 1.0 mg/mL, and epinephrine (Xylocaine adrenalin; AstraZeneca, Södertälje,
Sweden). To reduce pain, we applied a lidocaine
prilocaine cream (EMLA, AstraZeneca) for an hour to
richly innervated areas, such as the groin, before the
injections. The solution was injected and infiltrated
around and not directly into the affected site to
282 Lapins, Sartorius, and Emtestam
J AM ACAD DERMATOL
AUGUST 2002
Table I. Baseline characteristics of the 34 patients
treated for hidradenitis suppurativa with scannerassisted carbon dioxide laser surgery
Variable
Age (y)
Sex (M/F)
Age at onset (y)
Disease duration (y)
Acne: past or present (yes/no)
Hereditary/nonhereditary variant†
Smoker/nonsmoker‡
Children (yes/no)
Follow-up (mo)
Value*
33.9 ⫾ 11.0
3/31
22.3 ⫾ 6.6
13.4 ⫾ 8.6
16/18
11/23
25/9
16/18
34.5 ⫾ 25.7
*Plus-minus values are means ⫾ standard deviation.
†
Family history of hidradenitis suppurativa in one or more first-degree relatives reported by the patient.
‡
Smoking reported by the patients at the time of surgery.
avoid direct contact with inflamed tissue and injection into the abscess.
Scanner-assisted carbon dioxide laser surgery
The surgical technique with the scanner-assisted
carbon dioxide laser was modified from the previously used rapid hand movement– controlled carbon dioxide laser method15 and takes advantage of
the introduction of carbon dioxide laser scanners
(rapid-beam optomechanical microprocessed scanner system 1993-1994: SwiftLase model 755 [ESCSharplan Lasers, Inc, Allendale, NJ] 1995-2000: SilkTouch model 765 [ESC-Sharplan Lasers]). A focusing
handpiece from a Sharplan carbon dioxide laser
1030 is attached to the miniature optomechanical
flash scanner delivery system that generates a focal
spot, which rapidly and homogeneously spiral scans
and covers a round area on tissue at the focal plane.
The area selected was ablated with the laser beam
by passing it over the tissues, and this was followed
by repeated ablations in the same manner after devitalized tissues were removed by cleansing the surface with a swab soaked in 0.9% sodium chloride
solution. The depth of each level of vaporization is
controlled by the selection of power, focal length,
scanner-controlled spot size, and the velocity of the
movements of the hand-held scanner. We used 20 to
30 W, a spot size of 3- to 6-mm, and a focal length
setting of 12.5 or 18 cm. The vaporization procedure
is repeated in downward and outward directions
until fresh yellow adipose tissue is exposed in the
deep, relatively thin and anatomically normal skin
margins laterally, with no remaining dense or discolored tissue. Usually the vaporization reached the
deep subcutaneous fat or fascia. In the axillary region, major vessels and the nerve plexus must be
protected, but this depth was seldom reached in the
Hurley stage II14 lesions in this study. The smaller
blood vessels were coagulated by the laser, but
bleeding from vessels larger than 0.5 to 1 mm in
diameter should be stopped with electrocoagulation
or ligation. The wound, left to heal by secondary
intention, was immediately covered with dry dressings or ointment-impregnated dressings and a covering bandage attached with surgical adhesive tape
or gauze underwear.
Postoperative therapy
The patients remained in the department for 3
hours after the procedure for assessment of function
and to permit them to have a bowel movement,
empty the bladder, and discover any bleeding before leaving. The dressings were initially left on for 2
or 3 days without changing to prevent early bleeding. Thereafter, the wound was cleaned and rinsed
with tap water, and the bandage was changed as
often as necessary, sometimes daily, pending complete healing. Since 1998, a hydrofiber dressing
(Aquacel; ConvaTec Ltd, Deeside, UK) has been
used. Patients are usually able to change dressings
without professional help. The wounds were inspected after 1 week and then, until they healed, if
there were signs of complications. Wounds were
also examined at 6 weeks and 6 months after surgery.
Questionnaire
For the purpose of assessment of the clinical
postoperative course, persistent or recurrent HS, and
late sequelae after discharge, the patients were
asked in a letter to take part in a telephone interview
including questions on healing time, recurrences,
and satisfaction. Recurrence was defined as persistent or new signs of HS in any of the operated areas.
On follow-up during the telephone interview, they
were asked questions by two of the authors, neither
of whom was directly involved in surgery (K. S. and
L. E.), including the following: How was the postoperative period regarding pain (0, none; 1, did not
interfere with daily activities; 2, did interfere with
daily activities; or 3, prevented other activities)? As a
whole, is your disease now better than before surgery (yes, no, same, or no opinion)? In case of
recurrence, would you choose this laser method for
treatment again (yes, no, or undecided)? Do you
have or have you had acne (yes, no)? Do you have
first-degree relatives with HS (history of one or more
boils in axillary or inguinal area) (yes, no)?
RESULTS
Table I summarizes the baseline characteristics of
the patients who completed the follow-up.
J AM ACAD DERMATOL
VOLUME 47, NUMBER 2
Lapins, Sartorius, and Emtestam 283
Fig 2. Same woman as in Fig 1. A, Immediately after carbon dioxide laser surgery performed
with the optomechanical microprocessed flash scanner on the axilla. B, 1 week. C, 3 weeks.
D, 3 months later, healing without surgical closure of defect but by secondary intention.
The modified minimal invasive carbon dioxide
laser method was performed in 34 patients (31
women) with a mean age of 33.9 years (range, 15-55
years). One male patient was lost to follow-up. He
did not respond to our invitation to participate in the
telephone interview. The mean age at onset of disease was 22.3 years (range, 5-37 years). The areas
treated varied from 5 to 50 cm2 in area in a total of
67 operating sites (1 in sixteen, 2 in ten, 3 in two, 4
in four, and 5 in two cases). In most cases, the
duration of the procedure, including anesthesia, was
less than 20 minutes. Each lesion was vaporized in a
few minutes. The mean follow-up time was 34.5
months (range, 7-87 months). A typical case is
shown in Figs 1 and 2.
The mean healing time was 4 weeks (range, 3-5
weeks). Four patients had recurrences in the scars of
treated lesions less than 6 months after surgery. The
remaining patients had no recurrence in the treated
regions, but in 12 patients, new lesions or recurrences ⬎5 cm away from the operation scars developed more than 8 months after surgery. Twenty-five
of the patients had recurrences of their HS in an
anatomic region different from the one on which
surgery had been performed. Eight patients had no
apparent symptoms from their HS. Table II shows
the results of the follow-up. On a scale from 0 to 3,
four patients classified their pain in the postoperative period as 3, fifteen as 2, nine as 1, and six as 0.
Table II. Number of recurrences after scannerassisted carbon dioxide laser treatment of 34 patients
with hidradenitis suppurativa
None
In operated areas
In same anatomic region, but ⬎5 cm
from operated area
In another anatomic region
8
4
12
25
After healing, at the time of interview, 31 patients
considered that their condition was better than before surgery, two patients considered that their condition had hardly changed, and one patient thought
it was worse. The treated and most troublesome
areas had become asymptomatic, except in 4 cases.
Although there was much postoperative scarring,
the patients’ general and local functions were not
impaired. All but one of them were pleased with the
appearance of their scars after complete wound
healing. One inguinal scar in a female patient was
hypertrophic after delayed healing and ulcerated in
a 10-mm area during the first 2 months after surgery.
However, it healed after a single intralesional injection of steroids.
Postoperative course
Hospitalization was not needed, but professional
medical assistance for wound care was necessary in
284 Lapins, Sartorius, and Emtestam
4 cases. Only minor bleeding during cleaning of the
wound was reported. There were no secondary infections. One patient had an episode of paresthesia
in the arm lasting for 6 months after axillary surgery,
which then subsided. Twenty patients were able to
resume their regular jobs in less than 3 days. Four
had to stop work for 4 to 8 days, and 10, for 2 to 3
weeks. Patients who had undergone other surgical
methods for this condition preferred our laser
method, and all patients but one would have accepted the same type of laser surgery again, if necessary.
DISCUSSION
The carbon dioxide laser has previously been
used in HS surgery.16,17 Before scanner devices became available, we used a carbon dioxide laser operating at 30 W15,18 with a manually controlled handpiece. Tissue vaporization with freehand movement
is very dependent on the surgeon’s experience.
The rapid-beam microprocessor-controlled optomechanical scanner system uses parallel mirrors to
produce a fine spiral beam with an extremely short
laser exposure time, ablating tissue with minimum
thermal injury.19,20 When set at the continuous
mode, the scanned laser beam drills downward into
the tissues and removes the lesion rapidly in an even
and controlled manner. This provides a bloodless
operating field, which permits macroscopic examination of the pathologic features of the tissue. The
main aim is to attempt to maintain a majority of the
uninvolved tissue with appropriate surgical margins
for radicality and thus provide a better chance of
cure and a smaller defect that can result in a lesser
scar. The carbon dioxide laser has been used by
others to excise HS lesions.21 Excision technique is
essential in cases requiring pathologic anatomic examination to rule out suspected squamous cell carcinoma. This method is also of value in removal of
larger amounts of tissue from HS lesions.
The scanner makes ablation quicker, smoother,
and more precise than the freehand, surgeon-dependent technique. It also permits early detection
and minimal unintended damage of healthy or vascular tissues. Special caution is recommended in
patients who have a low ratio of diseased skin to
healthy subcutaneous tissue underlying the lesions
or in whom the procedure is limited by muscular
fascia or vital parts other than subcutaneous fat (ie,
nerves and blood vessels). In this study, we suspected an injury to an axillary nerve because one
patient complained of paresthesia that lasted for 6
months after surgery.
The hypothesis underlying this surgical method is
that radical removal and vaporization of macroscop-
J AM ACAD DERMATOL
AUGUST 2002
ically active HS tissue will prevent recurrences. It is
thought that if the epithelial sinuses produce keratin
and harbor debris and the bacteria survive the treatment, the epithelial sinuses will be the locus of
recurrence.
Postoperative wound care
Four patients stated that their pain after surgery
made other activities impossible, and 15 stated that it
interfered with daily activities. In our experience,
the pain during care of the wound (ie, changing the
dressings) was the most difficult aspect of the postoperative course in these patients. The hydrofiber
bandage used in our department since 1998 seemed
to be less painful to remove than other dry or ointment-impregnated dressings. This should be studied
in a controlled manner.
Most patients seen in departments of dermatology and many patients with HS have a milder
course, usually Hurley stage II,14 that is, recurrent
abscesses with tract formation, cicatrization, and single or multiple widely separated lesions that have
not yet become more severe. Although they cannot
be considered candidates for advanced major plastic
surgery, they do have a chronic disabling disease.22
In our study, 4 patients had recurrences in the
scars of treated lesions, and 12 patients had new
lesions or recurrences at a distance of ⬎5 cm from
the surgical scars. Twenty-five patients had active
HS in other areas. Only 8 patients had no apparent
symptoms from their HS. Our results are in accord
with those achieved with other surgical methods,23,24 and the need to repeat the treatment must
be considered. Development of new abscesses outside symptomatic skin area cannot be prevented by
any known surgical method and seems to indicate
activity of the underlying disease rather than a shortcoming of the method.23 Treatment with the laser
can be repeated, and because it is tissue-sparing, can
result in smaller scars. In cases of disease that recur
after carbon dioxide laser surgery, laser surgery
should be done again, but in conjunction with supplementary medical management such as long-term
administration of tetracyclines, retinoids, or cyproterone acetate.
However, some limitations should also be noted
in the interpretation of our findings. First, the outpatient files were analyzed retrospectively, and during follow-up, all patients were interviewed by telephone with the use of a questionnaire. This
information was therefore reported by the patient.
Second, because of the small number of patients, the
results of surgery are sensitive to chance effects.
Third, our patients had been referred to us by other
specialists who had treated them unsuccessfully
J AM ACAD DERMATOL
VOLUME 47, NUMBER 2
with other methods. Therefore, we may have selected patients with a relatively more therapy-resistant type of HS. Finally, our patients had Hurley stage
II disease,14 which we regarded as operable with this
method. In our department, patients with disease
classified as Hurley stage III are referred to plastic
surgeons for wide excision and reconstructive surgery. However, Hurley stage II is the most common
type of HS.25 When patients were considered to be
suitable candidates for surgery, they were usually
operated in our department; only a few were referred for wide-excision surgery.
In conclusion, our results indicate that in patients
with chronic HS, macroscopically controlled, tissueselective, and skin-preserving scanner-assisted carbon dioxide laser treatment is a safe and rapid surgical method with satisfactory cosmetic and
functional results and is suitable for use on an outpatient basis. The use of carbon dioxide laser microprocessor-controlled scanner devices has made the
technique safer and less surgeon-dependent. The
technique allows early treatment of HS lesions that
were previously managed with less effective local
conservative remedies.
We thank Dr Zoe and Francis P. Walsh for linguistic
revision and Gun-Britt Karlberg for technical assistance.
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