Journal of Cutaneous and Aesthetic Surgery
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BRIEF COMMUNICATION  
Year : 2012  |  Volume : 5  |  Issue : 3  |  Page : 190-192
Use of lasers for the management of refractory cases of hidradenitis suppurativa and pilonidal sinus


Divyakiran Skin Diseases Treatment, Lasers and Cosmetology Centre, Chippi Tank, Meerut, Uttar Pradesh, India

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Date of Web Publication26-Sep-2012
 

   Abstract 

Background: Hidradinitis suppurativa (HS) and pilonidal sinus (PNS) are chronic inflamatory skin diseases, often refractory to treatment and search for a new treatment is on. We tried deroofing with the help of carbon dioxide laser in patients of HS and PNS, however there was recurrence. Aim: To evaluate a technique combining the use of CO 2 laser and long pulse 1064 nm Neodymium-doped Yttrium Aluminium Garnet (Nd:YAG) laser for the treatment of HS and PNS. Materials and Methods: In 4 patients with HS and 5 patients with PNS, we performed procedure in two steps: first destroying the hair follicles with long pulse Nd yag 1064 laserfollowed by deroofing with carbon di oxide laser. Follow up was done upto 3 years. Results: All patients with HS were females in the age group of 30-40 years. In PNS, 2 male patients were of age less than 20, two male patients of age more than 20 and one females of age less than 20. None of the HS or PNS patients showed recurrence. Conclusion: The deroofing with CO 2 laser along with hair follicle removal with long pulse Nd:YAG laser is an effective minimally invasive tissue saving surgical intervention for the treatment of refractory HS and PNS lesions.

Keywords: Hidradenitis suppurativa, PNS-pilonidal sinus, Carbon dioxide laser, Long pulse Nd:YAG Laser

How to cite this article:
Jain V, Jain A. Use of lasers for the management of refractory cases of hidradenitis suppurativa and pilonidal sinus. J Cutan Aesthet Surg 2012;5:190-2

How to cite this URL:
Jain V, Jain A. Use of lasers for the management of refractory cases of hidradenitis suppurativa and pilonidal sinus. J Cutan Aesthet Surg [serial online] 2012 [cited 2019 Aug 23];5:190-2. Available from: http://www.jcasonline.com/text.asp?2012/5/3/190/101377



   Introduction Top


Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease. It is also known as acne inversa and is usually refractory to treatment. It is now considered as a disease of follicular occlusion rather than an inflammatory or infectious process of the apocrine glands. Clinically, the disease often presents with tender subcutaneous nodules beginning around puberty. The nodules may spontaneously rupture or coalesce, forming painful, deep dermal abscesses. Eventually, fibrosis and the formation of extensive sinus tract may occur. [1]

A pilonidal cyst, also referred to as a pilonidal abscess, pilonidal sinus (PNS) or sacrococcygeal fistula is a cyst or abscess near or on the natal cleft of the buttocks that often contains hair and skin debris. It involves mainly apocrine gland bearing areas of the body, most commonly axillary, inguinal, and anogenital regions (Pilonidal Sinus). This painful condition adversely affects the quality of life of patients.

We initially treated three patients of PNS and two patients of HS with carbon dioxide (CO 2 ) laser alone, but the disease recurred. Therefore, we tried a combination of CO 2 laser with 1064 nm long pulse Neodymium-doped Yttrium Aluminium Garnet (Nd:YAG) laser. Here, we report the results of a pilot study on deroofing with CO 2 laser and use of long pulse Nd:YAG laser to destroy hair follicles in four patients with HS and five patients with PNS with follow up of up to 3 years.


   Materials and Methods Top


In 4 patients with HS and 5 patients with PNS an open trial with CO 2 laser and long pulse Nd:YAG (1064) laser was done. All four patients with HS were females in the age range of 30-40 years. One patient had only one axilla involved, two patients had both the axillae involved while remaining 1 patient had both axillae and both sides of groin involved. In PNS, 2 male patients of age less than 20, two male patients of age more than 20 and one females of age less than 20

Informed consent was obtained from all patients. Initially, long pulse Nd:YAG laser1064 (Synchro-Play Systems, Deka, Italy) was used to remove hair on area with parameter of 10 mm spot size, 30 ms, 30 J with pre cooling and post cooling. Then deroofing was done after 15 days with CO 2 laser (Morexel, Korea) operating at 30 W in continuous ablative mode. Purpose of delaying the deroofing till 15 days after the hair removal by laser was to get totally hair free area.

For deroofing, skin was disinfected with 0.05 mg/ml of chlorhexidine solution. Local anaesthesia was used in the form of 1% lidocaine plus adrenaline (5 μgm/ml). The lesions were then explored with blunt forceps inserted in to the sinus openings [Figure 1]a and b. All communicating tracts were explored. The roofs of tracts were removed with the help of evaporation by CO 2 and floor of lesions were exposed [Figure 1]c. All communicating sinus tracts were opened in the same way using forceps as a guide to channels. The slough present at the bottom of all tracts was carefully evaporated and cleaned with the help of CO 2 laser and scrapped by simple gauze. Then surgical wound was left open to heal by secondary intention [Figure 1]d.
Figure 1: (a) Hidradenitis suppurativa with multiple sinuses, tracts, and cysts; (b) Forceps inserted to explore extent of tract; (c) Multiple tracts after deroofing and hair removal; (d) After complete healing

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In two cases of PNS, few hairs were still present which were destroyed by 1064 nm long pulse Nd:YAG laser at the same time and debris was curetted out. Post-operatively, cleaning was done at alternate days with hydrogen peroxide (H 2 O 2) and normal saline and then Mupirocin ointment was applied and wound covered with gauze pieces for initial 7 days. This dressing was done at the clinic. Subsequently, the patient was trained to wash the wound twice daily with diluted potassium permanganate solution and apply Mupirocin ointment. They were asked to take oral antibiotics and anti inflammatory medicines for the initial 10 days. Complete healing resulted in about 15 days [Figure 2]a-c.
Figure 2: (a) Draining pilonidal sinus; (b) Hair tuft in tract of pilonidal sinus after deroofing; (c) Healed lesions after 3 years with fine hair growth

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Subsequently, Long Pulse Nd:YAG was repeated in all patients at 2-3 month gap for four to five times. During this time, no recurrence was observed.


   Discussion Top


HS has been associated with many disorders. Other disorders of follicular occlusion (acne conglobata, dissecting cellulitis of the scalp, and pilonidal cyst) are well-known associations with HS, and make up the so-called follicular occlusion tetrad. [1],[2],[3] The clinical assessment of severity of HS cases is done using the Hurley staging system. [4] Stage 1 comprises of abscess formation (single or multiple) without sinus tract and cicatrisation. Stage 2 is a moderate disease with one or more widely separated recurrent abscesses with tract formation and scars. Stage 3 is the most severe disease with multiple interconnected tracts and abscesses throughout an entire area.

HS and PNS are difficult to treat. Current treatment options are topical or oral antibiotics, hormonal therapies, radiotherapy, and retinoids in the form of oral isotretinion. [5],[6],[7] Surgical interventions include incision with drainage, electrosurgery, and carbon dioxide laser vaporisation. [8] Sometimes large skin areas are excised, and defects may be sutured, closed with grafts or left open for healing by secondary intention.

The treatment of choice depends on severity, disease course, and preference of patient. In chronic severe conditions, surgery is mandatory. Treating the disease at an early stage is considered essential, as delay in treatment could lead to a situation where disease activity gets out of control making wide surgical excision necessary. [9]

Various lasers and lights have been tried in isolation for HS and PNS in the past. [10],[11],[12],[13],[14] These include Intense pulse light, long pulse Nd:YAG laser and carbon dioxide laser. All these lasers and lights, used alone, were associated with recurrences. Therefore, we decided to combine long-pulse Nd:YAG and carbon dioxide lasers.

The technique described here is not difficult and can be performed in office setting. No general anaesthesia or hospitalisation is needed. Removal of epidermis and dermis containing damaged epidermal appendages is done easily with CO 2 laser. Within 4-5 days a patient can resume his/her work.

The conventional treatment of HS and PNS involve use of depilatory creams, but with this recurrence is a common due to recurring hair growth at the site. However with five to six sittings, of hair removal with laser, chances of recurrence are less. [10],[11] Out of the other hair removing lasers, long pulse Nd:YAG 1064 was chosen because of its longer wavelength. It is considered as safer for Indian skin type IV and V.

This study is based on a very small number of patients, so further studies with larger sample size are required.

 
   References Top

1.Alikhan A, Lynch PJ, Eisen DB. Hidradenitis suppurativa: A comprehensive review. J Am Acad Dermatol 2009;60:539-61;quiz 562-3.  Back to cited text no. 1
[PUBMED]    
2.Chicarilli ZN. Follicular occlusion triad: Hidradenitis suppurativa: Acne conglobata, and dissecting cellulitis of the scalp. Ann Plast Surg 1987;18:230-7.  Back to cited text no. 2
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3.Scheinfeld NS. A case of dissecting cellulitis and a review of the literature. Dermatol Online J 2003;9:8.  Back to cited text no. 3
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4.Hurley H. Dermatologic surgery, principles and practice. New York: Marcel Dekker; 1989.  Back to cited text no. 4
    
5.Lee Ra, Yoon A, Kist J. Hideradinitis suppurativa: An update. Adv Dermatol 2007;23:289-306.  Back to cited text no. 5
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6.Joseph MA, Jayaseelan E, Ganapathi B, Stephan J. Hideradinitis suppurativa treated with finesteride. J Dermatolog Treat 2005;16:75-8.  Back to cited text no. 6
    
7.Kraft JN, Searles GE. Hideradinitis suppurativa in 64 female patients: Retrospective study comparing oral antibiotics and antiandrogens therapy. J Cutan Med Surg 2007;11:125-31.  Back to cited text no. 7
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8.Lapins J, Sartarius K, Emtestam L. Scanner assisted carbon dioxide laser surgery: A retrospective follow up study of patients with hideradinitis suppurativa. J Am Acad Dermatol 2002;47:280-5.  Back to cited text no. 8
    
9.van der Zee HH, Prens EP, Boer J. Deroofing: A tissue-saving surgical technique for the treatment of mild to moderate hidradenitis suppurativa lesions. J Am Acad Dermatol 2010;63:475-80.  Back to cited text no. 9
[PUBMED]    
10.Ghnnam WM, Hafez DM. Laser hair removal as adjunct to surgery for pilonidal sinus: Our initial experience. J Cutan Aesthet Surg 2011;4:192-5.  Back to cited text no. 10
[PUBMED]  Medknow Journal  
11.Ganjoo A. Laser hair reduction for pilonidal sinus-My experience. J Cutan Aesthet Surg 2011;4:196.  Back to cited text no. 11
    
12.Highton L, Chan WY, Khwaja N, Laitung JK. Treatment of hidradenitis suppurativa with intense pulsed light: A prospective study. Plast Reconstr Surg 2011;128:459-65  Back to cited text no. 12
    
13.Mahmoud BH, Tierney E, Hexsel CL, Pui J, Ozog DM, Hamzavi IH. Prospective controlled clinical and histopathologic study of hidradenitis suppurativa treated with the long-pulsed neodymium:yttrium-aluminium-garnet laser. J Am Acad Dermatol 2010;62:637-45.  Back to cited text no. 13
[PUBMED]    
14.Hazen PG, Hazen BP. Hidradenitis suppurativa: successful treatment using carbon dioxide laser excision and marsupialization. Dermatol Surg 2010;36:208-13.  Back to cited text no. 14
[PUBMED]    

Top
Correspondence Address:
Archana Jain
Divyakiran Skin Diseases Treatment, Lasers and Cosmetology Centre, 9- B Chetan Medical Complex, Near R.G. Inter College and Loyal Book Depot, Chippi Tank, Meerut, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2077.101377

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    Figures

  [Figure 1], [Figure 2]

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