*Hidradenitis Suppurativa Perineal and Perianal DOI: http://dx.doi.org/10.5772/intechopen.105632*

treatment. Even though their effects were demonstrated mostly in small case series, there is strong evidence based on large randomized controlled trials supporting the use of adalimumab (anti-TNF). In one of these studies, patients received weekly dose of adalimumab and 58.9% of them achieved at least 50% of reduction in acute lesion count, with no increase in abscesses [31–33].

More effective treatment involves several therapeutic strategies together, considering the severity and distribution of the lesions. Clinical and social income conditions of the patient may be considered to guide the proper management [31–33].

Some studies indicated that the best perineal/perianal outcome with the lowest recurrence rate is the surgical removal of all apocrine tissue with ill glands and subsequent reconstruction [21, 28, 32].


*Adapted from Zouboulis et al. [21], and Ingram et al. [28].*

*CO2: carbon dioxide; Nd:YAG: long-pulsed neodymium:yttrium-aluminum-garnet laser; IPL: intense pulse light; PDT: photodynamic therapy; and PUVA: bath psoralen plus ultraviolet A*

#### **Table 6.**

*Recommendations for surgical treatment of hidradenitis supurativa according to Hurley Stage.*

As an adjuvant measure, the use of hyperbaric oxygen therapy has been satisfactory in cases of extensive surgical resections as well [29]. In addition, among patients undergoing postoperative reconstructions with the creation of flaps that evolve with complications, such as necrosis or infection, hyperbaric oxygen therapy presented excellent results, with a shorter healing time [28, 29, 33].

Treatment for HS is established according to the Hurley stage, which classifies it into three degrees of severity, as shown in **Table 6**.

Punch debridement is recommended to treat acute inflammatory nodes. This is known as the "mini unroofing" procedure: a single follicle is evacuated by partially removing its roof. Surgical unroofing (deroofing management) can also be performed in Hurley stages II or III [31, 33].

A similar procedure referred as skin-tissue-saving excision with electrosurgical peeling (STEEP) is an alternative to wide excision. It may be performed on local or extensively affected tissue areas. It consists of careful unroofing and debridement of sinuses and inflamed tissue followed by scrubbing. This can be alternatively made with a carbon dioxide laser [31–33].

Incision and drainage alone lead to high recurrence levels and are, therefore, not recommended as a single treatment. However, it may be useful for pain relief [33, 34].

Sweeping excision is used to manage an extensive area of chronic HS (Hurley stage III), particularly when conservative measures fail. It is not curative but generally leads to long periods without recurrence. The entire affected area is removed until the normal-appearing subcutaneous fat is evident [28, 34].

**Figures 2**–**5** demonstrate selected cases of HS and extensive lesion resections.

In our experience, patients with mild/moderate HS confined to a small area tend to respond to clinical and simple pharmacological treatment (topical and/or oral antibiotics). In cases of refractoriness and high inflammatory activity, adalimumab associated with antibiotics should be a great option to control the symptoms and extension of HS.

#### **Figure 2.**

*Hidradenitis suppurativa lesions in the perianal and perineal region. (a) Preoperative and (b) immediate postoperative aspects.*

*Hidradenitis Suppurativa Perineal and Perianal DOI: http://dx.doi.org/10.5772/intechopen.105632*

**Figure 3.** *Extensive HS resections (a, b, c—immediate and d—late).*

#### **Figure 4.**

*Patient underwent modified radical vulvectomy. Preoperative (a), intraoperative (b), and reconstruction primary (c) image of the external genitalia marked scarring and fistulous tracts were evident in the pubis, vulva, and groin.*

#### **Figure 5.**

*Extensive resection in the gluteus and perineum of HS with closure by second intention. Preoperative (a) and postoperative (b) immediate.*

Among patients presenting scars, tunnels, and contractures or chronic refractory lesions, surgery should be considered. Localized lesions allow small procedures such as deroofing; nevertheless, in severe and extensive injuries, the size of intervention associates inversely with recurrence rates.
