Plastic Surgery and Jaw Injuries Centre, Queen Victoria Hospital, East Grinstead, Sussex

Transcription

1 SURGICAL TREATMENT OF SUPPURATIVE HIDRADENITIS By D. WYNN WILLIAMS, M.S.(Lond.), F.R.C.S. Plastic Surgery and Jaw Injuries Centre, Queen Victoria Hospital, East Grinstead, Sussex SUPPURATIVE hidradenitis is a clinical entity which has passed almost unrecognised in British surgical literature despite the many descriptions to be found in dermatological works and the comprehensive reviews of the disease by Christensen (i95o) and by Conway and Stark (i952). The first description was by Velpeau (i839), who called attention to a "particular circumscribed inflammation and superficial abscess of the axillary, mammary, and perianal regions." Verneuil (1854) confirmed the original description and suggested the sweat glands as the site of the recurrent inflammation. Considerable confusion concerning the diagnosis remained until Brunsting (1939) published a detailed description of the disease, since when such terms as "chronic abscess or furunculosis of axillse and buttocks," "recurrent fistulse of the perianal region," "pilonidal sinus of the axilla," have been discarded. Prior to the anatomical researches of Robin (1845) only two types of skin glands had been recognised. The first were the sebaceous glands situated adjacent to the hair follicle and joined to it by a short duct; these compound tubo-alveolar glands are found everywhere on the surface of the body except in the hollow of the palm and the sole of the foot. The second were the simple tubular sweat glands, the ducts of which spiral as they ascend through the dermis and epidermis to the surface of the skin; they are recognised by the term "eccrine " (or small sweat) glands and are distributed generally over the body surface. They secrete a dilute solution of sodium chloride and urea, and are densest on the palms and soles of the feet, less dense on the head, trunk, and extremities. Robin described a third type which had not been recognised before and have been named the apocrine (or large sweat) glands. They differ in structure from the eccrine glands in that the body (or coil) of the gland is larger and the duct is wider and tends to divide dichotomously into small tubules which end in blind sacs situated deeply in the subcutaneous tissues. Instead of opening on the surface like the small sweat glands, the apocrine glands open into the hair follicles between the" funnel" and the mouth of the sebaceous gland. The excretion of the apocrine glands differs from that of the eccrine glands in that it also contains part of the cell substance, and has a characteristic smell. They may be considered to be a connective link between the eccrine glands and the sebaceous (holocrine) glands. As they are active during menstruation and pregnancy, and in the lower animals work as a scent gland of sexual function, they have been considered as " cutaneous sex glands." Greeley (1951) suggests that the apocrine glands do not function until puberty, and in man they may be considered as a vestigial remnant. Woollard (193o) studied the phylogenetic significance of these glands in mammals and in man. He described the "axillary organ" as occupying the centre of the axilla, 3 F* 23x

2 232 BRITISH JOURNAL OF PLASTIC SURGERY measuring about 50 ram. in length, 2 ram. in width, and 3 to 5 ram. in thickness, and suggested that the term " anal organ" might apply to the circumanal region, as it is analogous to the axillary organ. Apocrine glands are situated in the following localkies :-- I. The axill~. 2. Inguinal and genital regions. 3. Around the anus (the glands of Gay). 4. The mamm~, especially in the areolar region. The ceruminous glands of the external audkory meatus are similar in structure but differ in that their cells are filled with fat droplets and brown pigment granules. Clinical Description.--Suppurative hidradenitis is a disease occurring at or after puberty, affecting females more frequently than males. The use of depilatories and deodorants has been stated to be the main causative factor ; however, no convincing evidence has been shown to confirm this theory. Trauma appears to pay little or no part in the majority of cases. The possibility of a psychological or endocrine factor must be mentioned, especially in view of the onset of the disease often occurring at the age of puberty. Acute Phase.--The onset of the condition follows closely that of any acute cutaneous lesion. One or more red and tender nodules appear in one of the sites of the apocrine glands, the inflammation continuing for two to seven days ; at the end of this period a soft area appears in the centre of the nodule, but fluctuation may be difficult to elicit; the epidermis begins to exfoliate and subsequently a discharge of a small amount of thin, oily fluid may occur ; this discharge will continue for some days or even weeks, thickening and becoming fcctid. The redness in the centre and at the edges will then fade, but the induration characteristically remains unchanged. In those nodules not discharging spontaneously, nor being incised surgically, termination may occur (I) by resolution or absorption of the abscess contents, these becoming caseous and absorbed, leaving a fibrous scar (2) in most instances there develops a gradual onset of the chronic phase, with variable intervals of temporary relief from fresh outbreaks of inflammation. Simultaneously wkh the onset of the chronic phase in one area, acute exacerbations may occur in other apocrine areas. Chronic Phase.taRed and tender nodules reappear surrounded by an area of brawny induration frequently associated wkh enlargement of the regional lymph nodules ; this gives rise to more severe pain than occurred in the initial acute phase ; sinuses develop which discharge a thick, yellow, fcetid material ~ the opening of the sinus is large, due to the necrosis of the surrounding epithelium. The walls of the infectcd gland break down and subcutaneous "tunnelling" develops. A probe entered through one sinus opening may be passed in many directions and out through the opening of other sinuses ; this feature is particularly noted in infection ofthe perianal region. The necrosis surrounding the sinus may extend in the line of the tunnelling and leave exposed tracts lined by unhealthy granulation tissue ; such tracts may be bridged at certain points by intact skin ; the surrounding skin has an atrophic appearance of a deep cyanotic colour, so commonly scen in chronic pyogenic infections. Fibrosis of the subcutaneous tissue develops in excess, especially in the lines

3 SURGICAL TREATMENT OF SUPPURATIVE HIDRADENITIS 233 of the subcutaneous tracts, giving rise to "tight bands " which limit movement in the flexures, especially noted in the axilla. The following three cases are described :m Case I.--G. B., female, aged 28 years. Occupation: housewife. At the age of 22 years, following the weaning of her only child, she noticed a tender swelling in her right axilla, and within a few days similar swellings had developed in both axillm. Local treatment by bathing with warm water relieved the condition and the" boils" discharged. With only a few days' remission between the onset of new " crops of boils " this condition continued in both axillm for three and a half years. At this stage she began attending the skin department of a London hospital, but FIG. I FIG. 2 Right and left axillm showing multiple active sinuses and scarring with limitation of abduction. throughout two and a half years of treatment she continued to suffer chronic infection in both axilla~. Treatment prior to Surgery.--(i) Full courses of the sulphonamide group of drugs and penicillin. (2) X-rays--three applications to both axillm, IOO r. (3) Infra-red therapy. (4) Insulin injections of IO units once a day for five days. (5) Local applications of aureomycin. Examination.--Normal, healthy female ; weight, IO st. 4 lb. C.V.S., C.N.S., R.S. : normal. B.P., 116/66. Urine normal. Axillce.--Heavily scarred on both sides with numerous discharging sinuses. No palpable axillary nodes (Figs. I and 2). Blood Count.--Hb, 82 per cent. (11"3 g. per IOO ml.). R.B.C., 4,42o,ooo per c.mm. W.B.C., 7,3oo per c.mm. E.S.R., 4 mm. Glucose tolerance test normal. Culture of Axillary Discharge.--Coagulase-negative staphylococci--resistant to penicillin. Surgical Treatment under General Amesthesia.--Complete excision of all infected skin in both axillm together with a wide margin of normal skin. This excision was carried down to the deep fascia and included all subcutaneous ex_tension~ of the sinusesleaving

4 234 BRITISH JOURNAL OF PLASTIC SURGERY a smooth bed of healthy tissue. The subsequent raw areas were covered by split-skin grafts cut by a dermatome. Both grafts were satisfactory, and the total length of time in hospital amounted to four weeks before complete epithelialisation. The patient has been free from any recurrence for eighteen months. Case 2.--A. W., male, aged 43 years. Occupation : tanner. At the age of IO years he developed infantile paralysis with a residual paralysis of the left leg which had nccessitated the use of an axillary crutch. Twenty-nine years later he developed a boil in the left axilla, and believing it to have been caused by an abrasion from the crutch, he disregarded it; two weeks later it was incised and drained by his local doctor, healing was slow, and epithelialisation did not occur for three months. For the subsequent six months he was free from boils, but then a further two boils developed in the same axiua ; these were similarly treated but failed to heal. He was treated at the skin department of a London hospital, but during the next three years he was never free from axillary suppuration, and two sinuses developed in the skin of the anterior axilla wall on the left side. Treatment prior to Surgery.--(I) Full courses of sulphonamide group of drugs and penicillin. (2) X-rays--four applications of ioo r. Examination.--A rather heavy man ; weight, 13 st. 4 lb. Residual paralysis of the whole of the left leg with shortening. C.V.S., C.N.S., R.S. : normal. B.P., 124/8o. Urine normal. Left Axilla. ~ Multiple discharging sinuses with considerable fibrosis limiting abduction of the arm. Probing of the sinuses demonstrated subcu- FIG. 3 taneous tunnelling. Left axilla two years after free grafting. Surgical Treatment.~Complete excision of all infected skin and a wide margin of normal skin. Removal of all underlying subcutaneous fat involved in the abscess and sinus formation. A thin split-skin graft applied to the raw area. The graft was satisfactory and he was discharged home in three weeks. The patient has been free from any recurrence for two years (Fig. 3). Case 3.mJ. K., female, aged I9 years. Occupation : student nurse. At the age of I2 years while living in South Africa she developed bilateral inguinal abscesses, which were treated by incision and drainage. Recurrences continued sporadically for eighteen months, and by the age of I4 years 6 months she was free from abscesses in this region. Six months later, at about the time menstruation began, she developed a left axillary boil ; this was treated by incision and drainage, but failed to heal for six months. The right axiua became involved one year later, and from that time till seen in this hospital she had never been free from axillary boils or discharge. Treatment prior to Surgery.--(I) Full courses of sulphonamide drugs and penicillin, chloromycetin, and aureomycin. (2) X-raysmfour applications to both axillm, 5o r. (3) Infra-red therapy. (4) Thyroid extract, I g. daily for three months. Examination.--A rather obese girl ; height, 5 ft. 6 in. ; weight, I2 st. 6 lb., but in excellent general health. C.N.S., C.V.S., R.S. : normal. B.P., 11o/7 o. X-ray: chest normal. Urine normal. Axill e.--multiple discharging sinuses in both axillm~ with considerable surrounding

5 SURGICAL TREATMENT OF SUPPURATIVE HIDRADENITIS 235 fibrosis limiting abduction of her arms, the left being more restricted than the right. No palpable glands in either axilla. Breasts.--Right, normal. Left, old healed sinuses on skin overlying the axillary tail. Groins.--Old healed sinus in both groins. No palpable glands. Culture of Discharge from Axilla.--A scanty growth of coagulase-negative staphylococci--resistant to penicillin and aureomycin. Anaerobic culture negative. Surgical Treatment.--(I) Left Axilla : Complete excision of involved area of skin and subcutaneous fat. A split-skin graft cut by a dermatome was placed to cover the raw area. (2) Right Axilla : Three weeks later complete excision of involved area of skin and subcutaneous fat and direct closure by local flaps. Pathological Report of Tissue removed from Case 3.--Both pieces of axillary skin show extensive epithelial proliferation, with keratinisation and some inclusion of epithelial-lined cystic spaces. The corium contains clumps of dilated apocrine glands, some in the active phase. There are clumps of small round cells with areas of giant-cell infiltration. Summary.--The appearances are suggestive of a previous chronic inflammatory condition with consequent dilatation and retention of the contents of the apocrine glands. DISCUSSION The initial clinical appearance of suppurative hidradenitis closely resembles a boil, but the subsequent course, prognosis, and pathological findings differ markedly, and the inflammatory changes are localised to the areas of the body in which apocrine glands are found. The chronic nature of the disease and the subcutaneous tunnelling, together with the appearance of the skin surrounding the sinuses, superficially resembles a tuberculous lesion. Goldsmith (r95o), after repeated attempts, failed to culture the tubercle bacillus. Greeley (I95 r) suggested an anaerobic bacillus as the primary organism. Repeated attempts at anaerobic culture in Case 3 of this series failed to confirm this theory, and it would seem that the organisms so far demonstrated are all secondary infectors. Marks (r95i) suggested the possibility of a primary metabolic dysfunction, as he found a low basal metabolic rate, chronic fatigue, and hypocholesterremia in some cases under his care. It is of interest that in Cases r and 3 of this small series treatment by insulin and thyroid failed to effect any improvement. That the onset of the condition is often reported to occur at the age of puberty suggests that further investigations in the field of endocrinology are indicated. The diagnosis of suppurative hidradenitis is commonly overlooked because of the insidious nature of the onset and the close clinical resemblance of furtmcles occurring elsewhere ; it is therefore not surprising that a great variety of treatments have been advised. Of the many local applications, ~ per cent. phenol with I : 5oo bichloride of mercury in 7o per cent. alcohol advised by Brunsting (I939), and Phisoderm soap with hexachlorophene, are reported as beneficial. The antibiotics have been given a wide trial, but except for the oral administration of terramycin in a dosage of 25o mg. four-hourly they do not appear to have altered the course of the disease, but their value is to reduce the post-inflammatory fibrosis and to prevent post-operative bactera:mia. The use of X-ray and infra-red therapy has proved of little value in the treatment of the condition. Surgery appears to offer the most effective treatment in both the acute and the

6 236 BRITISH JOURNAL OF PLASTIC SURGERY chronic phase. For the former, incision and free drainage should be carried out as soon as fluctuation is obtained. Careful probing of the abscess cavity at the operation should be performed, and if subcutaneous tunnels be found these must be laid open and the overhanging FIG. 4 Dermatome graft in position with circumferential sutures. FIG. 5 Method of fixation of the dermatome graft. skin margins excised. Packing of the abscess cavities is undesirable as drainage is impaired rather than improved. Most patients are referred to the plastic surgeon in the chronic phase of the disease, and in the majority of cases the lesions are in the axill~e ; for it is the anatomical position and the function in this region that necessitate plastic procedures rather than repeated incisions being performed. The main underlying plastic surgical measure in the axilla is a wide excision of all infected skin together with the involved underlying subcutaneous fatty tissue.

7 SURGICAL TREATMENT OF SUPPURATIVE HIDRADENITIS 237 The design of the margins of the excised area must be such as to prevent web contractures developing at a later date. The excision of subcutaneous fatty tissue must remove all sinuses and tracts down to the fascia. No record can be found of these ever extending through the fascia to involve the main vessels or nerves in the axilla. The preparation of the fatty bed to receive the graft must include absolute hmmostasis and the removal of all fatty tags that may necrose under the graft or flap. Subsequent repair of the defect may be by local flaps or by free skin grafting. The method of fixation of the free skin graft is by circumferential black silk sutures, the long ends of which are tied over layers of flavine wool and gauze, and by these means even pressijre can be obtained (Figs. 4 and 5). SUMMARY Suppurative hidradenitis is described as a clinical entity due to infection of the apocrine glands. Three cases are described. The possible mtiology is discussed and the surgical treatment outlined. I wish to thank Sir ArchibaM Mclndoe for permission to publish the first and third cases and Mr Watson for the second case ; Dr Barbara Evans for the pathological report, and Mr Clemetson for the photographs. REFERENCES BRUNSTING, H. A. (1939). Arch. Derm. Syph., N.Y., 39, lo8. CHRISTENSEN, J. B. (195o). Amer. ft. Surg., 79, 61. CONWAY, H., and STARK, R. B. (1952). Surg. Gynec. Obstet., 95,453. GOLDSMITH, W. N. (195o). Proc. R. Soc. Med., 43, 171. GREELEY, P. W. (1951). Blast. reconstr. Surg., 7, 143. MARKS, M. M. (1951). Amer. ff. Surg., 79, 64. ROBIN, C. (1845). Ann. Sci. nat., 4, 38o. VELPEAU, A. (1839). "Aisselle,... Dictionnaire de m6decine, un r6pertoire g~n6ral des sciences m6dicales sous la rapport theorique et pratique," ed. 2. Bechet jeune, , vol ii, p. 91. " Anus," ibid., vol. iii, p. 3o4. " Mamelles," ibid., vol. xix, p. I. VERNEUIL, A. (1854). Arch. gdn. Mdd., 4, 447, 693. WOOLLARD, H. H. (193o). ft. Anat., Lond., 64, 415.