Dr. Volshteyn is a board certified plastic surgeon who performs medical, laser and surgical treatments of hidradenitis suppurativa.
Depending on your physical location, stage and location of the lesions, we can select a proper treatment for you or your child.
If needed, depending on extent and location of the lesions, Dr. Volshteyn may recruit other surgeons to assist him during surgery or other specialists to assist in complex medical management, including endocrinologist, dermatologist, pain management specialist and others.
We do offer HS related laser hair removal, ND:YAG laser, Botox, endoscopic, laser-assisted, and suction-assisted and other medical and minimally invasive treatments in addition to traditional surgery.
INSURANCE CONSIDERATIONS. Hidradenitis Suppurativa is a medical condition. Some treatments, like excisions, skin grafts and flaps, may be covered by most insurance plans. Others, like laser hair removal, liposuction of glands, Botox treatments are not.
Most insurance plans do not appreciate the extent and complexity of treating hidradenitis suppurativa. Even though we do not participate as in-network providers with most carriers, we are able to accept payments from most commercial plans (PPO and POS) with out-of-network benefits.
Depending on your individual insurance plan, you may be responsible for deductible and coinsurance. We welcome payments through direct contracting (employer sponsored plans), FLEX plans or HSA accounts. Global Cash payment plans are available after evaluation. We also accept most credit cards and offer financing through Care Credit and other vendors.
Hidradenitis suppurativa, aka Velpeau Disease, or Verveuil’s Disease, or Acne Inversa is a complex medical condition. In some form its mechanism of progression is similar to acne.
Formal definition of this disease was adopted in 2009 at a meeting sponsored by Hidradenitis Suppurativa Foundation: “HS 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, inguinal, and ano-genital regions”
Hydradenitis suppurativa develops more commonly in women in the areas where skin rubs together. It usually occurs around hair follicles with large number of deep and long oil and sweat glands. It can start at puberty and continue for many years. Commonly it worsens overtime. Hydradenitis suppurativa can affect one or more areas at a time. Hydradenitis suppurativa affects up to 1-4% of US population (3-12 million people). Many authors believe that there is no racial predisposition but there is one study that suggests increased incidence in blacks due to 3 times increased density of sweat glands. Both men and women are affected but some areas of anatomy are favored by men and others by women.
Most common areas to develop hidradenitis suppurativa are armpits, groin, perianal area, between and under the buttocks and in between and under the breasts.
Signs of hidradenitis suppurativa may include blackheads, or red, small pea-sized tender bumps under the skin that sometimes can break open and drain pus; chronically open wounds that drain and eventually develop scar tissue. They usually start with small red spot that later becomes tender. About 50% of patients are able to predict 1-2 days before the lesion appears with burning, stinging, pain, itching, or excessive sweating.
The first time it was described as separate disease in 1839 by a French surgeon Alfred-Armand-Louis-Marie Velpeau. By the way, he was also the first one to describe leukemia, femoral hernia and invent proper chest wall bandage.
The mechanism of hidradenitis is not clear. We believe that because of age, genetics, excess weight, lack of hygiene, changes in hormones, smoking, diabetes and possibly other factors, the oil and sweat gland opening around hair follicles and hair follicles themselves become blocked. As the result, the inner skin layer of hair follicles becomes brittle and easy to break. The sweat and oil produced inside of those glands cannot escape, it builds up and eventually gets infected. Because the glands are deep, and located under the skin, pressure inside of them can make those glands even longer and bigger, or even rupture the glands and hair follicles, eventually forming long tunnels under the skin filled with oil secretions and fowl smelling pus.
Recurrent infections create pitted scars in the skin, rope-like scars under the skin, open sores, pain and difficulty with movement, draining fowl smelling pus, social isolation and embarrassment. It is not clear why hidradenitis suppurativa occurs in the proximity of large lymph nodes, like in the groin and armpit areas, but inflammation from infected deep sweat glands can also interfere with normal lymph drainage function in those areas. Chronic wounds for over 10 years can also lead to skin cancer.
There is also poorly understood association with arthritis and Crohn’s disease. Some doctors believe that there is autoimmune component to hidradenitis suppurativa and that is why in some patients the immunosuppressant medications work.
Medical clinical presentation has several Stages by Hurley Classification:
- Single or several lesions without scarring or sinus tracts;
- Recurrent widely separated lesions with sinus tracts;
- Diffuse involvement with sinus tracts and abscesses.
There is also a Sartorius scale for dynamic staging based on location, separation of lesions and scars based on point system but clinically it is not practically relevant, so I do not use it.
Dermatologic Quality of Life Index DLQI had been developed to determine how a condition affects a patient and recent study documented a very significant negative impact on patient’s lives, greater then psoriasis.
Experienced centers use high frequency ultrasound to identify the extent, proximity to vital structures and tunneling.
Treatment of hidradenitis is better and easier in early stages. The larger the affected area the more difficult the treatment is.
Home remedies include warm compresses with Burow’s Solution (water based aluminum acetate, aka Domeboro, Star-Otic, Borofair), washing with antibacterial soaps (or 6.25% aluminum chloride hexahydrate in absolute alcohol) several times a day or Hibiclens (chlorhexidine gluconate) daily or weekly depending on severity, keeping soft air permeable and absorbable pad in affected areas, wear loose fitting cloths, laser hair removal, avoiding synthetic fabrics, quitting smoking, losing weight, taking Zinc Gluconate 30 mg TID and Tumeric supplements.
Shaving had been thought to worsen hidradenitis suppurativa, however, studies do not support that. Still, it is important to keep hair short. Using a shaving blade is not easy on inflamed tissues, so I recommend a mechanical shaver.
The deodorant that rolls on the skin can promote infection and cross contaminate skin on the other side or even other parts of the body. Use a spray instead.
Dietary modifications can also decrease chances of recurrence. Decrease foods high in saturated fats, limit chocolates and pastry, do not eat processed meats, decrease dairy intake.
Laser hair removal had been used with some success in patients with hidradentits suppurativa stage 1 in combination with other modalities to reduce recurrence.
Antibiotics (tetracyclines, doxycyclines, minocycline, Bactrim, clindamycin, erythromycin, dapsone) can treat acute infection, decrease chances for recurrence but they have to be taken for many years. For Hurley Stage 1 patients, Augmentin with or without steroids can be used at the very onset of disease or early signs. 10 week regimen of Clindamycin and Rifampin 600 mg each is commonly used for annual maintenance and decreased recurrence.
Corticosteroids (triamcinolone, prednisone, prednisolone) in the form of injection or pill can decrease inflammation and soften scarring but long term use of steroids has its own set of complications.
TNF Alpha inhibitors (Humira, Remicade) can decrease inflammation but they can increase risk of infections, heart failure and some cancers.
Isotretinoin has been a main stay of hidradenitis suppurativa treatment in 1980 and 1990 but only 16-17% of patients demonstrated improvement.
Hormone modulation therapy (antiandrogens, like spironolactone, or Cyproterone acetate, or estrogen derivatives like athinyl estradiol) had been shown to be beneficial.
1064 ND:YAG laser had been used to reduce severity of disease with some success.
Botox had been shown to be effective in reducing the disease in stage 1 pediatric patients for up to 6-10 month.
Liposuction techniques had been used to remove oil glands on the undersurface of the skin and reduce recurrence with some success.
Incision and drainage of solitary lesions or de-roofing of infected tunnels can help to decrease infection but it does not cure the problem.
CO2 laser excision and marsupialization (cutting out a cyst and suturing edges so it does not recur) is a technique similar to traditional excision of pilonidal cysts and limited to lesions in early remission but not in acute stage.
The gold standard is surgical removal of affected areas and glands all together.
Limited incision of isolated small lesion has 50% chance of recurrence.
Aggressive excision is used in more advances disease and usually requires a 2 cm margin of normal looking skin to remove most of deep tunnels. It is very difficult if not impossible to close the wound primarily after aggressive excision.
Main healing methods described after excision are
- letting wound heal by secondary intention over silicone to decrease scarring;
- eusing VAC, negative pressure wound healing system;
- Skin graft;
- local rotation skin flaps (Limberg);
- perforator flaps (thoracodorsal, medial arm and others)
- free flaps
Unfortunately, risk of recurrence is very high even with most aggressive methods. It is 3-50% over 6 years depending on location, method and margin of surgery. Some patients develop satellite lesions in the areas next to previous surgeries never affected before by hidradenitis suppurativa.
Radiation had been used for hidradenitis suppurativa with some success with energy up to 8 gray however, it is not a mainstay treatment due to concern of potential cancer development.
The problem with Hydradenitis Suppurativa is that despite affecting millions of people, most physicians, including emergency room doctors, primary care physicians and surgeons, know too little about it. It is important to remember that most treatments do not cure the disease.
The only definitive treatment is aggressive surgery but it is complicated by scarring, recurrence, healing problems, etc.
They key to success to proper, meticulous and consistent care.
ICD 10 Coding
L73.2 Hydradenitis Suppurativa
L73.0 Acne Keloid
L73.9 Follicular Disorder unspecified
For your reference I also include a list and some links to articles of relevance on treatment of hidradenitis suppurativa.
Use of Botox in Hidradenitis Suppurativa