EP245 - Severe Perineal Hidradenitis Suppurativa: A Case Report and Literature Review

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Purpose/Background: Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition characterized by deep-seated nodules, abscesses, and sinus tracts, typically affecting the axillae, perineum, and inframammary regions. Severe cases are associated with chronic scarring and infection, psychosocial distress, and neoplasia. Surgical management is reserved for refractory cases, and includes abscess drainage and unroofing or excision of the affected, pilo-sebaceous skin. We report on a case of severe groin and perianal HS, and review current treatment options and emerging therapies.

Methods/Interventions: A 44-year-old male with Hurley Stage III HS affecting the groins, scrotum, perineum, perianal tissues, and buttocks presented to our care. His condition was refractory to topical and systemic antibiotics, and biologic therapy (adalimumab, upadacitinib). Multiple incision and drainage procedures were required for abscess palliation. He had previously responded well to wide local excision of axillary disease with skin grafting. Given the extent and severity of the disease, staged surgical excision with fecal diversion and skin grafting was recommended.

Results/Outcomes: In the index procedure, laparoscopic diverting ileostomy and wide local excision of scrotal and groin disease was performed with skin grafting; unfortunately these grafts failed due to hostile wound environment (excess moisture and exudate). Subsequent excision of perianal, intergluteal and buttocks disease was performed four weeks later, with application of a woven fiber allograft (Restrata). The total surface area excised exceeded 500 cm^2. Multiple additional debridements with repeated allograft application to the intergluteal cleft were required. Now six months after his index procedure, there is no active HS in the perineum or intergluteal cleft; however, epithelialization of the resultant surgical wound remains incomplete.

Conclusion/Discussion: Surgery is traditionally reserved for refractory HS; extensive excision procedures of the intertriginous regions, while curative, may create debilitating chronic wounds and contractures. Traditional surgical techniques (e.g., skin grafts) as well as novel allografts are crucial to the treatment of large chronic wounds. Restrata, in particular, has demonstrated utility in accelerating healing of large wounds with high microbial burden. However, these grafts may not survive the hostile intertriginous environment, which suffers from high shear stress and poor aeration. Emerging biologic medications, including JAK, IL-17, and IL-12/23 inhibitors, have been shown to modify even refractory disease activity, and may avoid the need for radical surgery in the future.