Hidradenitis suppurativa: a case study Barbara Topley and Sandra Brain

Abstract

This article identifies the care and treatment of a male patient during an acute flare up of hidradenitis suppurativa (HS). This article looks at HS, which can be a progressive chronic condition that impacts heavily on all aspects of a patient’s quality of life. The choice of a silver alginate dressing proved effective in managing multiple surgical wounds in a comfortable and effective manner, improving the patient’s quality of life. Key words: Hidradenitis n Infected sinus tracts n Silver alginate dressing

M

r T is a patient admitted to hospital for treatment of an acute infection in the tissues of his buttocks, groin and perianal areas. He had a long-term history of hidradenitis suppurativa (HS). As the disease advanced, it was classified as stage III. Mr T required surgical intervention to open up infected sinus tracts to allow drainage of pus and exudate, and healing by secondary intention. He was selected as part of a wider study involving 49 patients examining the role of calcium alginate dressings in patients with haemo-purulent or haemo-serous discharge in chronic wounds (Smith and Gibson, 2013).

What is HS? HS is an acne-related disease associated with the apocrine sweat glands and is sometimes referred to as acne inversa or apocrine acne. Whereas the eccrine glands secrete sweat directly onto the skin, the apocrine glands secrete thick milky fluid that contains the sex hormone androgen, into the hair follicle shaft. In HS, it is believed that the apocrine ducts become blocked, trapping the secretions and bacteria that then develop into either a single or multiple abscesses. These inflamed boil-like nodules either slowly disappear or erupt as painful suppurative abscesses. Although healing occurs, the affected skin is left with deep scarring. There are periods of remission, though as the disease progresses, the condition becomes chronic. More diffuse multiple abscesses occur with the formation of a network of sinus tracks accompanied by pockets of induration.

Histopathology studies in the 1980s and 1990s proved that HS is primarily an acne-related disease caused by occlusion and rupture of the hair follicles resulting in the apocrine glands becoming infected. There is a paucity of information on this disease that was initially identified and described by a French physician, Alfred Velpeau, in 1839. There is thought to be a familial link and predisposing factors include obesity and smoking. Factors that aggravate the condition include stress, heat, sweating and friction; 50% of women with HS are reported to have a flare-up of the disease prior to menstruation. There is a possibility that HS could be related to hormones as the condition usually starts after the onset of puberty and the disease in women subsides after the menopause (Von Werth, 2001). Although a clearer understanding of this non-contagious disease has emerged during the past 40  years, there is an ongoing debate regarding the aetiology of HS. Recent studies have identified HS as a disorder of follicular occlusion rather than apocrine occlusion. HS affects 1–2% of the population and affects all ethnicities. It is more often seen in people with black skin as they have a higher density of apocrine glands compared with other ethnic groups (Beshara, 2010). HS begins around an average age of 23 years old, and is more likely to affect women than men (Von der Werth, 2001). The most common sites are the axillae and groins, but it can also affect the perineum, perineal and suprapubic regions, abdominal folds and also in hairy areas. Beshara (2010) states that: ‘The onset can be insidious and the severity of the symptoms can vary widely. Single or multiple nodules or abscesses of varying sizes form and can resolve within a few days or can progress into chronic cutaneous or subcutaneous sinus tracts’. There can be occasional or frequent episodes of inflammation. Sometimes raised cord–like tissue develops as a result of dermal contractures or comedones that require incision and drainage of the area that can leave non–healing wounds. HS is a painful condition that can persist for years. In more advance cases, two thirds of sufferers have chronic lesions that do not heal because of the development of subcutaneous epithelial-lined tracts that remain in a constant state of inflammatory activity (Von der Werth, 2001).

Barbara Topley is Tissue Viability Clinical Nurse Specialist, Portsmouth Hospitals NHS Trust; Sandra Brain is Tissue Viability Nurse Specialist, Portsmouth Hospitals NHS Trust Accepted for publication: July 2013

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When Mr T was 21 years old, he was treated three times for pilonidal sinus. Mr T was diagnosed with HS at the age of 30. He periodically underwent surgery to drain the buttocks, groin and axilla abscesses. The diseased tissue in both axillas was eventually excised followed by skin grafting. At 53 years old, 5 feet 11 inches tall and weighing 68 kg, Mr T presented to the surgical assessment unit with an acute

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A case study

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Stage

Characteristics

I

Solitary or multiple isolated abscess formation without scarring or sinus tracts (a few minor sites with rare inflammation that may be mistaken for acne)

II

Recurrent abscesses, single or multiple widely separated lesions, with sinus tract formation (frequent inflammation restrict movement and may require minor surgery such as incision and drainage)

III

Diffuse or broad involvement across a regional area with multiple interconnected sinus tracts and abscesses (inflammation to the size of golf balls, or sometimes baseballs; scarring develops, including subcutaneous tracts of infection

flare-up of HS. He was septic with a haemoglobin of 5.3 g/ dL, a white cell count of 15 (109/L) and C-reactive protein 170. He had chronic skin changes all over the buttocks with thick sclerotic scar tissue and fissures (Figures 1 and 2). There were areas of induration with pockets of fluid underneath draining from narrow sinus tracks. He had active abscesses in the groins, upper inner thighs and the scrotum. There was also a small abscess in the right chest area near the nipple. His weight had gradually fallen from 114 kg to 68 kg over a period of 18  months, with the most rapid amount lost in the last 3  months prior to his admission. He was unable to walk properly or sit down and needed to lie down due to the constant pain. Mr T was constipated and passing blood rectally. This was thought to be the cause of his low haemoglobin. Mr T had extensive scarring across both buttocks from previous surgery and multiple small open wounds with tracks beneath the skin draining haemopurulent exudate and pus. There was a deep track at the natal cleft with tracks in both groins and upper thighs. Due to the significant amount of pain Mr T was experiencing, he required high doses of opiate analgesia which exacerbated his constipation. To relieve constipation, Mr T was prescribed aperients to soften the stool and alleviate his pain.

Figures 1 and 2. On admission, all discoloured areas are pockets and tracks of deep infection

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Mr T was prescribed 3 units of blood and underwent investigations including an MRI scan, examination under anaesthetic, biopsies and a sigmoidoscopy. Wound management was comprehensive. Mr T showered with an antibacterial wash. Dermol emollient was applied topically in order to reduce bacteria on the skin and reduce the risk of blocking the hair follicles. Dressing pads were used as a secondary dressing to absorb the high volume of exudate and secured with close-fitting pants to avoid the use of any adhesive tapes. He was reviewed by a multidisciplinary team including plastic surgeons, general surgeons and dermatologists before a decision was made to treat Mr T surgically. Mr T underwent a surgical procedure to lay open the infected network of tracts caused by the HS (Figures 3 and 4). He also had a sigmoidoscopy to 60 cm to rule out low bowel fistulae. More than 20 tracks of subcutaneous tissue and deeper areas were layed open over buttocks, natal cleft, groins, scrotum and inner thighs. He also had a small wound on the upper right side of the chest wall, below the nipple that was also excised. A calcium alginate dressing (Sorbsan) was used to pack the multiple wounds and a total of 14 packs were required at this time. Mesorb was prescribed as a secondary dressing to absorb excess exudate and reduce the risk of maceration. It was extremely difficult to dress all the wounds and Mr T was at high risk of re-infection due to his general poor health, sepsis and faecal contamination. As the wounds were sloughy and draining blood and pus. Mr  T agreed to trial a silver calcium alginate dressing (Sorbsan Silver), as studies had shown that it was effective in controlling bleeding, reducing bacteria and encouraging granulation tissue (European Pressure Ulcer Advisory Panel (EPUAP), 2012). Sorbsan Silver application was started five days after surgery The following day the wounds had improved, with less pus and blood. Six days later, the wounds had improved and were clean and granulating. Despite being exposed to faecal contamination, the wounds did not become infected. A week later, the shallower wounds were healing well and the deeper fissures were clean, with evidence of granulation. There was no evidence of bleeding or purulent discharge. Plans were made to discharge Mr T home under the care of a district nurse. Mr T was discharged 38 days following admission. Three months after discharge (Figures 5, 6 and 7), Mr T was reviewed by his surgeon and the tissue viability nurse specialist. Although Mr T had some repeated episodes of infection and required antibiotics, the majority of wounds had almost healed. He continued to have three small tracts that were suppurating, but these were not extensive. District nurses had initially visited Mr T daily to renew his dressings. Mr T was keen to return to work, so to facilitate this, his wife was taught how to dress the wounds. His care was then transferred to the practice nurse, who reviewed Mr T weekly. The plastic surgeon offered further radical surgery and to debride the three remaining tracts and scar tissue. At this time, Mr T had returned to work, he had recovered from a septic event, and during his absence from work he was very concerned about his financial commitments, and supporting his family by maintaining employment was paramount. HS can be devastating, and in some situations like Mr T’s, can be life-threatening. The impact on the patient and his family is immeasurable. While his employers had been supportive

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Table 1. Staging: Hurley’s staging system is used to describe the severity of HS (Hurley 1989)

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Figure 3. Demonstrating extent of fissures to be radically debrided

Figure 4. Wounds laid open to drain blood and pus

during his hospital stay, Mr T remained concerned, particularly about losing his job in the current economic climate in Portsmouth. It was important the tissue viability team took this into account when planning his discharge and wound care support in the community. Encouraging his family to take an active role in his wound care meant that he did not need to take valuable time away from work. The community nurses worked closely with the hospital team, which meant appointments were kept to a minimum. A contingency plan was made to open the tracks and drain them in the future, should these areas continue to be problematic.

Beshara (2010) emphasises the importance of hygiene in managing HS. Mr T showers twice a day using Dermol. His wife expresses pus and clear fluid from the apertures in the buttocks by palpating the indurated areas. A suggestion to use an emollient to hydrate the skin was declined as Mr T and his wife found that the skin became clogged and increased the infections. The presence of bacteria can compromise chronic wounds and can result in the breakdown of extra-cellular matrix, destruction of healthy tissue and prolong the inflammatory response.(Coutts and Sibbald, 2005). Mr T’s condition fluctuated between chronic and infected wounds, especially over the buttocks. It is recommended that systemic antibiotics are used to treat invasive infection and topical antimicrobials used for superficial and local management of wounds (European Wound Management Association (EWMA), 2006). Oral antibiotics can be used to suppress inflammation in HS (Beshara, 2010) and Mr T began taking low doses to reduce the risk of further infections and keep the condition under control.

Discussion

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Mr T’s case study demonstrates that he followed the classic pattern of HS.There is a link between pilonidal sinus and HS, and Mr T experienced three episodes during his twenties. HS was identified when he was in his early thirties. Mr T had the condition for more than 20  years and admitted to reluctance to seek medical treatment. His wife had helped manage his wounds during this time and developed strategies to enable him to adapt his lifestyle to manage the condition. His disease had progressed to stage III (Table 1), and it was not until the wounds on his buttocks became infected that he sought medical help. Von der Werth (2001) cites that one reason for the lack of progress in treating HS is patients’ reluctance to seek medical intervention, often preferring to conceal their condition. Although a variety of treatment options are available, some patients feel that treatment for this chronic disease has not progressed since first identified and described by Velpeau in 1839.

Surgical intervention Radical surgery is considered effective for the later stages of HS. However, this may necessitate the removal of the entire infected area followed by skin grafting. It is not unknown for the disease to develop in another area after surgery (Beshara, 2010). Mr T had several operations in the past to excise the infected areas on his buttocks and groin. He also had the tissue excised in both axillas to remove the apocrine glands to try and prevent further disease progression, followed by skin grafting. On this occasion, Mr T subsequently had no problems with his left axilla, but he still experienced HS in the right axilla. The HS was so severe,

Figure 5. Challenges with applying dressings; Figure 6. Demonstration of waxy discharge that is expressed; Figure 7. Epithelialised fold associated with Hidradenitis

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Wound assessment The decision on the most appropriate dressings to use should be made following the outcome of a holistic assessment that identifies physical, psychological and social factors that can influence wound healing. Assessment is an ongoing process that needs modifying depending on a patient’s health status, medical condition and local wound management that should take into account a patient’s preferences (Benbow, 2011). Involving Mr T and his wife in developing a treatment plan ensured that his preferences were met.

Choice of dressing As Mr T had numerous painful wounds across his buttocks which were initially producing a high volume of haemoserous and heamopurulent exudate, a calcium alginate dressing (Sorbsan) was selected as a suitable primary dressing. Alginate dressings have the appearance of soft, conformable fabric that is designed to absorb exudate and facilitate painless removal. Smith and Gibson (2013) recommend assessing the type and volume of exudate before deciding on a primary dressing. It has also been demonstrated that alginates have haemostatic properties (Blaine, 1951). There are a variety of alginates available to clinicians and depending on their properties, the uptake of exudate can vary (Beldon, 2010). Some form an amporhous gel through the ionic exchange from calcium to sodium ions promoting haemostasis (Clark, 2012). Smith and Gibson (2013) advocated the use of an algorithm to aid decision making when choosing dressings for chronic wound management. The algorithm indicates the suitability of silver alginates to manage haemo-serous or haemo purulent infected wounds. Beshara (2010) recommends that the wounds of patients with HS be dressed with silver impregnated alginate dressings because of their antimicrobial action in reducing bacterial loading and managing exudate. During Mr T’s hospital stay, a study examining the role of silver calcium alginate dressings (Sorbsan Silver) in patients with haemopurulent or haemoserous discharge in chronic wounds was being undertaken by the tissue viability team. Mr T agreed to participate in the study that was being undertaken across 11 centres within the UK. A metaanalysis by Lo et al (2009), which included eight randomised controlled trials of silver dressings for non-healing wounds, concluded that the signs and symptoms associated with infection improved with silver dressings. The advantage of Sorbsan Silver was that it contained manuronic acid that is effective at closing the capillary gate on bleeding friable tissue, thus reducing excessive blood loss contained within the exudate. The alginate dressings were painlessly removed

Key points n Patients with HS suffer acute pain and embarrassment n Alginate dressings can easily be irrigated out of deep fissures n Patients can be encouraged to manage their own wounds

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from the multiple wounds by irrigating with saline. Choosing appropriate dressings is essential to meeting the needs of the patient and should not cause any discomfort during application or removal of dressings (Beldon, 2010). HS is a painful and disfiguring condition that may not be identified in the early stages. The treatment options are limited and not considered curative (Beshara, 2010).

Patient empowerment Although more common than initially thought, patients do not always have confidence in health professionals (Von der Werth, 2001). Providing support, information and education enhance the patient’s ability to manage HS (Beshara, 2010). Mr T and his wife had managed this condition for a number of years. Together, they had developed strategies to cope with this debilitating, painful and embarrassing condition. The tissue viability team were able to provide support and advice on managing multiple, highly exuding wounds, by using a silver alginate primary dressing and an effective secondary dressing to manage the exudate, thus enabling Mr T to return to work.

Conclusion There is a lack of knowledge and understanding of HS and more research is needed to identify the best treatment options. HS is a painful, debilitating and embarrassing condition. Understandably, patients lack confidence in health professionals and are reluctant to seek medical advice. This case study demonstrates how the tissue viability team were able to identify a suitable silver alginate dressing (Sorbsan Silver) to manage multiple, haemopurulent wounds. By providing practical support and education, the tissue viability team enabled the patient’s wife to manage his multiple wounds. Mr T was able to return to work and lead a near BJN normal life. Conflict of interest: none Alikhan A, Lynch PJ, Eisen DB (2009) Hidradenitis suppurativa: a comprehensive review. J Am Acad Dermatol 60(4): 539–61 Beldon P (2010) How to choose the appropriate dressing for each wound type. Wound Essentials 5: 140–4 Benbow M (2011) Wound care: ensuring a holistic and collaborative assessment. Wound Care 6(5): S6–S16 Beshara MA (2010) Hidradenitis suppurativa: a clinician’s tool for early diagnosis and treatment. Nurse Pract 35(5): 24-8 Blaine G (1951) Calcium Alginates and Haemostasis. Postgrad Med J 27: 613–20 Clark M, Duward R (2012) Novel methods for measuring the ability of wound dressings to contribute to blood coagulation. http://tinyurl.com/nygq9do (accessed 26 July 2013) Coutts P, Sibbald R (2005) The effect of a silver-containing hydrofibre dressings on superficial wound bed and bacterial balance of chronic wounds Int Wound J 2(4): 348–56 European Pressure Ulcer Advisory Panel (EPUAP) Identifying research gaps and clinical needs in pressure ulcer prevention and management. http:// tinyurl.com/d64r9cx (accessed 1 August 2013) European Wound Management Association (EWMA) (2006) Position Document: Management of wound infection. http://tinyurl.com/6he539h (accessed 26 July 2013) Hurley HJ (1989) Axillary hyperhidrosis, apocrine bromhidrosis, hidradenitis suppurativa, and familial benign pemphigus: surgical approach. In: Roenigk RK, Roenigk HH, eds. Dermatologic Surgery. Marcel Dekker, New York: 729–39 Lo S, Chang C, Hu W (2009) The effectiveness of silver dressings in the management ofnon-healing wounds: a meta-analysis J Clin Nurs 18(5): 716–28 Smith G, Gibson E (2013) The development of an algorithm to support nurses choosing dressings for chronic exudate. Wounds UK 9(2): 64–7 Von der Werth J MRCP Consultant Dermatoligist (2001) Hidradenitis suppurativa. Dermatol Pract 9(3): 22–5

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with a network of deep infected tracts, there was no other option than to lay open the wounds and allow them to drain.

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Hidradenitis suppurativa: a case study.

This article identifies the care and treatment of a male patient during an acute flare up of hidradenitis suppurativa (HS). This article looks at HS, ...
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