Subcutaneous curettage as a treatment modality for axillary hidradenitis suppurativa

INTRODUCTION

Hidradenitis suppurativa (HS) is a chronic, debilitating disease affecting the young adult population. It is a part of the follicular occlusion syndrome involving the intertriginous areas rich in apocrine glands, such as the axilla, groin, and inframammary area. Painful nodules, abscesses, sinus tract formation, and scarring characterize it.¹ HS is more prevalent in females (F: M 4:1).²

It is a relapsing disease of the folliculopilosebaceous units (FPSUs). The follicular unit gets blocked and enlarged by retained keratin due to a myriad of contributing factors, such as smoking, obesity, and genetic and hormonal factors. The damaged FPSU’s ductal contents rupture and leak due to friction, shearing stresses, and pressure, triggering an inflammatory response mostly mediated by the innate immune system.³

Early diagnosis and treatment can lower the chance that HS will deteriorate and proceed to severe stages. Due to the associated discomfort, foul-smelling discharge, and scarring, HS has a dreadful psychosocial impact.⁴

Management of HS is challenging, with the majority of patients requiring a combination of medical and surgical therapies.⁵ The early stages can be treated medically, but the latter stages will almost certainly necessitate surgery. Deroofing and local excision is performed for active disease. Certain surgical procedures – such as subcutaneous curettage alleviate the disease process and thus reduce recurrences.

MATERIAL AND METHODS

The research comprises a prospective analysis of the disease process and recurrences in six patients who underwent subcutaneous curettage for axillary HS in a tertiary care center in Bangalore.

All patients underwent routine blood investigations and written informed consent was obtained before the start of the procedure. Concurrent systemic medication that maintained remission in each patient was continued. Subcutaneous curettage was done once active lesions were under control. This procedure is aimed at reducing further recurrences and their intensity.

Under aseptic precautions, the axilla was painted and draped. A field block was given with lignocaine 2% with adrenaline 1:2,00,000. Solution for tumescent anesthesia was prepared by adding 100 mL of normal saline, 5 mL of 1% lignocaine, and 0.1 mL of 1:1,000 epinephrine. This solution was infiltrated into the axilla to make it firm and avoid damage to the underlying neurovascular bundle during the procedure.

Apocrine-rich portion of the axilla was marked in a pyriform shape [Figure 1a].

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Figure 1:

(a) Apocrine rich area marked before procedure. (b) Cannula used for subcutaneous curettage.

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A fat aspiration cannula was used for curettage [Figure 1b].

The entry point was made using a Number 11 blade. Cannula was passed into the subcutaneous plane through the entry point, in a to-and-fro motion by the dominant hand and counter pressure was applied over the skin with the non-dominant hand to help guide the tip of the cannula and achieve adequate curettage [Video 1 and Figure 2]. Additional entry points are made if needed to allow curettage of the entire marked area. The endpoint of curettage was ascertained by laxity of skin in the operative field.

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Figure 2:

Cannula passed through the entry point.

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Following curettage, a compression dressing was applied and changed every alternate day. Patients were prescribed oral diclofenac and antibiotics for 5 days post-procedure. Concurrent systemic medication continued. Compression was maintained for 10 days post-procedure. None of the six patients experienced adverse effects.

Simplified Sartorius score [Table 1] was used to assess the disease on the day of surgery and at follow-up. Patients were followed up at 12-week and 24-week intervals.

RESULTS

Simplified Sartorius score was used to assess disease severity on the day of surgery and at follow-up visits (12 and 24 weeks) [Table 2]. A statistically significant reduction in disease severity was observed in all patients over time [Table 3, Figure 3].

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Figure 3:

(a) At presentation. (b) At 24 weeks. (c) At presentation. (d) At 24 weeks.

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DISCUSSION

The severity of the illness and its subjective effects on each patient should guide therapy choices for HS.⁶ While medical treatments are advised for this multimodal disease, the standard of care for HS is surgical therapy, which has been demonstrated to be more successful because it ensures full healing of lesions, reduces the recurrence of lesions, and provides long-lasting local disease control. Research on different surgical procedures and reconstructive care has grown exponentially over the past years, offering patients more surgical options.⁷

Subcutaneous curettage is done to eliminate the “bulge” of the FPSU that houses the stem cells. These cells are implicated in stimulating the growth of the proliferative mass (dermal deposition of amorphous material) and sinus tracts.³ It disrupts the FPSUs responsible for disease perpetuation, offering a less invasive but effective surgical alternative. The technique provides durable results with minimal morbidity, especially when systemic therapy is concurrently used to control active inflammation.

Other surgical modalities for HS include incision and drainage, deroofing, limited or wide local excision, and skin grafting or flap reconstruction. Incision and drainage are typically discouraged due to high recurrence rates. Deroofing and excision offer more definitive management. Wide local excision, although effective in preventing recurrence, may involve significant morbidity and often necessitates complex reconstruction.⁸ Compared to wide excision, subcutaneous curettage is less invasive, does not require general anesthesia or hospitalization, and can be repeated if needed. Its tissue-sparing nature reduces downtime and improves patient compliance.

Adjunctive treatments such as laser hair reduction have been increasingly incorporated in HS management to reduce follicular occlusion, the initiating event in HS. Laser therapies – particularly long-pulsed neodymium-doped yttrium aluminum garnet (Nd: YAG) and diode lasers – have shown reductions in flare frequency and severity. Tierney et al.⁹ found that long-pulsed Nd: YAG laser therapy led to a significant drop in lesion count and improved patient-reported outcomes. Diode laser therapy has also been found to be effective in reducing recurrence in mild-to-moderate HS.¹⁰

The results from this case series suggest that subcutaneous curettage is a promising intervention for axillary HS. Further studies involving larger cohorts and randomized controlled designs are essential to confirm these findings and refine treatment protocols.

CONCLUSION

The study demonstrates a consistent and statistically significant reduction in lesion scores post-subcutaneous curettage. The greatest improvement in disease severity was observed at 24 weeks. Significant reduction in occurrence of new lesions was observed. Thus, reducing pill-burden and improving quality of life of the patient.