Outcomes After Combined Radical Resection and Targeted Biologic Therapy for the Management of Recalcitrant Hidradenitis Suppurativa

Abstract

Background Trials demonstrating the efficacy of biologic therapy for moderate to severe hidradenitis suppurativa (HS) have inspired new multidisciplinary treatment strategies. We present our experience with combined biologic and surgical therapy for recalcitrant HS. Methods Between 2011 and 2014, 21 patients (57 cases) with Hurley Stage III HS underwent radical resection with delayed primary closure alone, or in combination with adjuvant biologic therapy. Demographic data, treatment regimen, outcomes, and complications were retrospectively reviewed for all cases. Results Eleven patients underwent combined surgical and biologic therapy, whereas radical resection alone was performed in 10 patients. The average soft tissue deficit, before closure, for the combined and surgery-only patients was 56 cm2 and 48.5 cm2, respectively (P = 0.66). Biologic agents including infliximab (n = 8) and ustekinumab (n = 3) were initiated 2 to 3 weeks after closure and were continued for an average of 10.5 months. Recurrence was noted in 19% (4/29) and 38.5% (10/26) of previously treated sites for combined and surgery-only patients (P < 0.01). For the combined cohort, the disease-free interval was approximately 1 year longer on average (P < 0.001); however, this difference was reduced to 4.5 months when considering time to recurrence after cessation of biologic therapy (P = 0.09). New disease developed in 18% (2/11) and 50% (5/10) of combined and surgery-only patients, respectively (P < 001). No adverse events were noted among patients who received biologic therapy. Conclusions Lower rates of recurrence and disease progression, as well as a longer disease-free interval may be achieved with the use of adjuvant biologic therapy after radical resection for recalcitrant HS.

Longitudinal observational study of hidradenitis suppurativa: impact of surgical intervention with adjunctive biologic therapy

“…The analysis presented has allowed investigation of critically important clinical outcome questions in the management of HS that are challenging to address in randomized clinical trials. Specifically, one of the most important clinical questions in HS management is whether surgery alone, or in combination with biologic therapy, is the best management for HS and how best to time biologic therapy relative to surgical interventions …”

“…Surgery has been a mainstay of HS management for some time and is often used for patients with extensive Hurley stage III disease . The best results are achieved with wide local excision, but the disease often recurs, and this has led to a recent interest in the use of targeted biologic therapy in the management of HS …”

Hidradenitis suppurativa/acne inversa: a practical framework for treatment optimization – systematic review and recommendations from the HS ALLIANCE working group

“…Pre-and postoperative biologic therapy may lead to a lower recurrence rate and a longer disease-free interval 61,62 (evidence level 4, grade of recommendation C).…”

Interferon-gamma (IFN-γ) is Elevated in Wound Exudate from Hidradenitis Suppurativa

“…In support of this hypothesis, Ustekinumab (Stelara®), a monoclonal antibody targeting the IL-12/IL-23 common p40 subunit, has been effective in a small number of reported cases (Sharon, Garcia et al 2012). A retrospective study of surgical patients found lower rates of recurrence and disease progression, as well as longer disease-free interval in patients treated with adjuvant biologic therapy after radical resection for HS (DeFazio, Economides et al 2015). …”