Journal of Plastic, Reconstructive & Aesthetic Surgery
ReviewA systematic review of the use of lasers for the treatment of hidradenitis suppurativa
Introduction
Hidradenitis suppurativa (HS) is a chronic debilitating disease of the follicular epithelium, presenting most commonly after puberty, in the axillary, inguinal and anogenital regions. It was first described by Velpeau in 1839.1 Subsequently Verneuil described it to be in arising from sweat glands and coined the title hidradenitis suppurativa.2 Classically, HS was thought to represent a primary disorder of apocrine glands and was also referred to as apocrinitis.3 More recently, with increasing histological evidence, HS has come to be regarded as a disorder of the follicular epithelium. Follicular hyperkeratosis is considered to be the initial event, leading to occlusion, occasional secondary apocrine involvement, and follicular rupture with resultant inflammation and possibly secondary infection resulting in clinical findings of multiple inflamed nodules, cysts, abscesses and sinus tracts.4 Hidradenitis suppurativa has now thereby been classified as a member of the follicular occlusion triad, along with acne conglobata and dissecting cellulitis of the scalp, and more recently, the follicular occlusion tetrad as pilonidal sinus was added to the group.
A variety of topical and systemic preparations have been used to deal with this condition ranging from antibiotics, Isotretinoin, anti-androgens and various biological agents such as Adalimumab and Infliximab, many of which have been shown to be helpful to treat the disease and even reduce recurrence. These patients are often referred to plastic surgeons once they develop multiple abscesses that require drainage and are thought to benefit from surgical excision with or without skin grafting. However, the option of laser as another modality of treatment, given the current understanding of the pathogenesis of the disease, is not as well known. An informal survey of plastic surgeons revealed a lack of understanding of the advances in pathophysiology of the disease process and newer modalities of available treatment. As laser is an available resource for many plastic surgeons that perform repeated surgical procedures on such patients, the need was felt to review available data on the efficacy of laser for the treatment of HS.
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Data search
A review of available literature was performed by two individuals (HJ and NM) independently using MEDLINE, Cochrane and Pubmed databases from the first entry in May 1987 to October 31, 2015 (27 years). All relevant English language publications were reviewed using key search terms of ‘hidradenitis suppurativa’ in combination with ‘laser’ or ‘intense pulsed light’. Additionally, bibliographies of retrieved publications were manually searched to identify other sources. Abstracts were reviewed to
Results
Since the first paper published by Dalrymple et al. about the use of laser for Hidradenitis suppurativa in 1987,9 we identified 48 papers with relevance to our review; of which 22 studies met our inclusion and exclusion criteria. Of the 22 studies only 2 were graded as A, 1 as B and the rest (mostly case series, case reports or expert opinions) were given the lowest grade of C. The studies were further classified according to the type of laser that was used, these included Neodymium doped
Discussion
The international symposium of the Hidradenitis Suppurativa Foundation33 adopted a consensus definition of the disease stating that it is “a chronic, inflammatory, recurrent, debilitating, skin follicular disease that usually presents after puberty with painful, deep-seated inflamed lesions in the apocrine gland-bearing areas of the body, most commonly, the axillary, the inguinal and anogenital regions”.
Diagnosis requires three essential criteria:
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Typical lesions: deep-seated painful nodules,
Conclusion
From our analysis, there is moderate evidence to suggest the efficacy of long pulse NdYAG laser and intense pulsed light in treating HS and reducing the risk of recurrence, via the mechanism of hair removal-targeting the primary pathology in HS; and limited evidence suggesting the efficacy of carbon dioxide laser. This study also highlights the need for standardization of assessment techniques and the need for large, preferably multicentre, randomized controlled trials. A multidisciplinary
Conflict of interest
None.
Funding
Nil.
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