Subcutaneous curettage as a treatment modality for axillary hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic disease involving apocrine gland-rich areas of the body such as axilla, groin, and inframammary areas. It is characterized by painful nodules, abscesses, sinus tract formation, and scarring. The management of HS is one of the most formidable challenges in contemporary dermatosurgery. While medical therapies are essential for managing the inflammatory component of the disease, the structural damage seen in Hurley Stage II and III disease often requires a surgical approach.

The recent study by Suresh et al., “Subcutaneous curettage as a treatment modality for axillary hidradenitis suppurativa,” offers a tissue-sparing surgical technique.¹ By focusing on subcutaneous curettage for axillary disease, the authors favor less invasive, yet highly effective, surgical alternatives to traditional radical excision.¹

In HS, the follicular unit becomes blocked and enlarged by retained keratin. This enlarged follicular unit ruptures, triggering a massive innate immune response. This leads to chronic inflammation and eventual scarring.² The treatment options include drug therapy for the initial inflammatory phase and combined surgical and medical therapy for the destructive or scarring phase of the disease. Surgical options for the treatment of HS are used for acute pain relief or for the removal of scarred tissue. Deroofing of subcutaneous tunnels using cold steel surgery electrosurgery or laser limited or wide local excision followed by secondary intention healing or flap reconstruction are surgical modalities for the management of HS. Limited surgical procedures are associated with less complications but higher recurrence rate and wide excisions have lower recurrence but higher complication rate. Secondary intention healing after wide excision takes a long time, and flap reconstruction is a morbid surgery and requires expertise.³ There is a need to find minimally invasive surgical options in the management of HS. Subcutaneous curettage is an important innovation that has the potential to bridge this gap. Subcutaneous curettage results in the disruption of the disease-perpetuating structures. It eliminates the affected tissue as well as the bulge region of the follicular unit, which houses the stem cells responsible for stimulating the growth of sinus tracts. The disruption of these units leads to durable surgical results with minimal morbidity.

The methodology described by Suresh et al. highlights several critical steps that ensure both safety and efficacy.¹ The procedure begins with the tumescent anesthesia, which creates tissue turgidity, making the axilla firm and protecting the underlying neurovascular bundle from damage during the mechanical curettage. The surgical field is carefully defined by marking the apocrine-rich portion of the axilla. The intervention utilizes a fat aspiration cannula, which is passed through a small entry point made with a Number 11 blade. The surgeon uses a “to-and-fro” motion with the dominant hand while applying counter-pressure with the non-dominant hand to guide the cannula tip and ensure thorough tissue removal. The use of blunt cannula further reduces the chance of damage to the underlying neurovascular bundle. The endpoint of the procedure is the laxity of the skin in the operative field. Post-operative care involves a compression dressing for 10 days to minimize dead space and prevent complications. In this study’s cohort of six patients, no adverse effects were reported, underscoring the technique’s favorable safety profile when performed under appropriate aseptic conditions.

To objectively measure the success of the intervention, the authors utilized the simplified Sartorius score at baseline, 12 weeks, and 24 weeks. This scoring system includes nodules, fistulae, and the presence of normal skin between lesions to provide a standardized assessment of severity.⁴ The mean Sartorius score at baseline was 18.3, which dropped to 8.3 at 12 weeks and 3.3 at 24 weeks after the intervention. This reduction was statistically and clinically significant. These findings suggest that the benefits of subcutaneous curettage are not only immediate but also continue to improve over time as the tissue heals and the cycle of follicular occlusion is broken. When compared to other surgical modalities for HS, such as wide local excision, subcutaneous curettage offers several distinct advantages for both the patient and the practitioner. While wide excision is effective in preventing recurrence, it often results in significant morbidity, the need for general anesthesia, and complex reconstructive procedures. In contrast, subcutaneous curettage is far less invasive, conducted in local anesthesia, is a day-care procedure, and is tissue-sparing surgery. While the procedure is innovative and has numerous advantages, small sample size and lack of control group limit the generalizability of the findings. Retrospective study design can introduce selection bias in the study. The study has a short follow-up period for a chronic, relapsing disease like HS. The study by Suresh et al. demonstrates that subcutaneous curettage is a promising and effective intervention for axillary HS.¹ The consistent reduction in lesion scores and the high level of patient safety make it a valuable addition to the dermatosurgeon’s toolkit.