The surgeon's perspective: a retrospective study of wide local excisions taken to healthy subcutaneous fat in the management of advanced hidradenitis suppurativa

Background: Hidradenitis suppurativa (HS) is a chronic debilitating folliculopilosebaceous disease that affects the skin most commonly in the axilla, groin, inframammary, genital and buttock areas. Surgical intervention may be an appropriate option in selected cases, but there is a risk of recurrence. The purpose of this study was to assess the results of wide local excision (WLE) to healthy subcutaneous fat with secondary intention healing in patients with HS who were under concurrent surgical and dermatologic care. Methods: We conducted a retrospective review of 192 consecutive HS consultations to a general surgical service, identifying patients treated with WLE. Cases involving minor procedures (deroofing, incision and drainage) were excluded. Data on patient demographics, surgical site, method of closure, complications and recurrence were extracted from patient charts. We also conducted a literature review of surgical procedures in the management of HS. Results: A total of 66 patients underwent 133 WLE to healthy subcutaneous fat. All patients were under concurrent medical care directed by a dermatologist. No medical therapies, including biological treatments, were interrupted or withheld for surgery. One hundred procedures were closed primarily with rotation or advancement flaps and 33 by secondary intention healing. Local recurrence occurred in 18% of primary closures and 18% of secondary intention closures (p = 0.98, χ2 test, no difference between groups). One patient with secondary intention healing returned to the emergency department for bleeding; 34% of patients with primary closure experienced some dehiscence (23% major, 11% minor separation). Two patients with axillary disease had restrictions in their ability to raise their arm that required physiotherapy. Median follow-up was 14.5 (range 1­55) months. Conclusion: Resection to healthy subcutaneous fat during WLE provides disease control comparable to that with deeper resections, simplifying care.

Contexte: L'hidradénite suppurée (HS) est une maladie invalidante chronique du follicule pilo-sébacé qui affecte la peau principalement au niveau de l'aisselle, de l'aine, du pli sous-mammaire et du siège. Une intervention chirurgicale pourrait être une option appropriée dans certains cas, mais il y a un risque de récurrence. Le but de cette étude était d'évaluer les résultats d'une excision locale large (ELL) jusqu'aux tissus adipeux sous-cutanés sains suivie de cicatrisation secondaire chez des patients atteints d'HS recevant concomitamment des soins chirurgicaux et dermatologiques. Méthodes: Nous avons procédé à une revue rétrospective de 192 consultations consécutives pour HS dans un service de chirurgie générale et nous avons recensé les patients traités par ELL. Les cas impliquant des interventions mineures (par incisiondrainage) ont été exclus. Les données démographiques, le site chirurgical, la méthode de suture, les complications et les récurrences ont été enregistrés à partir des dossiers des patients. Nous avons aussi procédé à une revue de la littérature sur les interventions chirurgicales pour l'HS. Résultats: En tout, 66 patients ont subi 133 interventions d'ELL jusqu'aux tissus adipeux sous-cutanés sains. Tous les patients prenaient concomitamment un traitement médicamenteux sous la supervision d'un dermatologue. Aucun des traitements médicamenteux, y compris les agents biologiques, n'a été suspendu ou interrompu pour la chirurgie. Cent interventions ont été refermées principalement par lambeaux de rotation ou d'avancement et 33 par cicatrisation secondaire. Les récurrences locales ont affecté 18 % des fermetures primaires et 18 % des fermetures par cicatrisation secondaire (p = 0,98, test du χ2, aucune différence entre les groupes). Un patient soumis à la cicatrisation secondaire est retourné aux urgences pour un saignement; 34 % des patients ayant subi une fermeture primaire ont présenté un certain degré de déhiscence (23 % majeure, 11 % mineure). Deux patients ayant une atteinte axillaire ont connu des restrictions dans leur capacité de lever les bras et ont dû faire de la physiothérapie. Le suivi médian a été de 14,5 (éventail de 1 à 55) mois. Conclusion: La résection jusqu'aux tissus adipeux sous-cutanés sains durant l'ELL permet de maîtriser la maladie aussi bien que les résections plus profondes, mais simplifie les soins.

Prolactin/Jak2 directs apical/basal polarization and luminal linage maturation of mammary epithelial cells through regulation of the Erk1/2 pathway.

Tissue development/remodeling requires modulations in both cellular architecture and phenotype. Aberration in these processes leads to tumorigenesis. During the pregnancy/lactation cycle the mammary epithelial cells undergo complex morphological and phenotypic programs resulting in the acquisition of apical/basal (A/B) polarization and cellular maturation necessary for proper lactation. Still the hormonal regulations and cellular mechanisms controlling these events are not entirely elucidated. Here we show that prolactin (PRL)/Jak2 pathway in mammary epithelial cells uniquely signals to establish A/B polarity as determined by the apical localization of the tight junction protein zona occludens 1 (ZO-1) and the basal/lateral localization of E-cadherin, and the apical trafficking of lipid droplets. As well, our results indicate that this pathway regulates mammary stem cell hierarchy by inducing the differentiation of luminal progenitor (EpCAMhi/CD49fhi) cells to mature luminal (EpCAMhi/CD49flow) cells. Moreover, our data indicate that PRL/Jak2 coordinates both of these cellular events through limiting the mitogen activated protein kinase (Erk1/2) pathway. Together our findings define a novel unifying mechanism coupling mammary epithelial cell A/B polarization and terminal differentiation.