[Axillary hidrosadenitis due to Leishmania: Case report and literature review]. / Hidrosadenitis axilar por Leishmania: presentación de un caso y revisión de la bibliografía.

BACKGROUND: Hidradenitis is a disorder where abscesses appear after the infection of the apocrine sweat glands. It is located normally in the axillae, groin, perineal region, and the scalp. CLINICAL CASE: A 37 year old male was referred by his GP to the General Surgery Department with axillary hidradenitis which had evolved over the years. The physical examination shows signs of hidradenitis in both axillae, with a noticeable suppurative hidradenitis in the right armpit. En bloc extirpation was performed to remove the whole affected area. The pathological examination revealed a cutaneous leishmaniasis. Subsequently, fucidin was administered topically, as well as local infiltrations of one millilitre of Glucantime™. DISCUSSION: Hidradenitis normally appears in intertriginous areas and its manifestation is accompanied by recurrent subcutaneous nodules. The incidence rate in females is three times higher than in males. The isolated Hidradenitis caused by Leishmania is a rare condition presented only in endemic areas or in immunocompromised patients, such as HIV-infected patients. Clinical manifestations can be different and the diagnosis can be confirmed through haematoxylin-eosin. The main pattern displays a disorganised granuloma without necrosis. Systemic or topical treatment can be applied. Immunotherapy treatment is the most common. CONCLUSIONS: Hidradenitis caused by Leishmania in HIV-negative patients is a rare condition. Therefore it is important to perform a good histological diagnosis and to administer the right treatment.

Retalho fasciocutâneo torácico lateral para reconstrução de defeitos axilares após ressecção de hidradenite supurativa: série de 10 casos / Lateral thoracic fasciocutaneous flap for reconstruction of axillary defects after resection of hidradenitis suppurativa: a series of 10 cases

INTRODUÇÃO: A hidradenite supurativa (HS) é uma inflamação folicular crônica que apresenta quadro clínico variado, desde pequenos nódulos isolados até diversas lesões abscedadas, com formação de fístulas e cicatrizes. A região axilar é uma das áreas mais frequentemente acometidas. O objetivo é analisar uma série de casos acometidos por HS na região axilar, submetidos à exérese cirúrgica ampliada e reconstrução com retalho fasciocutâneo torácico lateral. MÉTODOS: Análise retrospectiva dos prontuários dos pacientes submetidos a tratamento no período entre 2010 e 2012. RESULTADOS: Dez pacientes foram operados, sendo que em dois havia acometimento bilateral, totalizando 12 procedimentos. Foi observado um tempo médio de evolução antes da indicação cirúrgica de 38 meses. O defeito médio observado após a ressecção foi de 10 x 9 cm. O tamanho médio dos retalhos foi de 15 x 10 cm. Em relação às complicações precoces, foram observados dois casos de deiscência (região axilar) e um caso de epiteliólise parcial (segmento distal do retalho). CONCLUSÃO: Observamos que a dissecção deste retalho não é tecnicamente difícil e que não apresenta sequelas funcionais ou estéticas significativas na área doadora, sendo uma opção confiável e versátil para reconstrução de defeitos axilares de maior porte.

INTRODUCTION: Hidradenitis suppurativa (HS) is a chronic follicular inflammation that presents varied clinical features, from isolated small nodules to several abscessed lesions, with formation of fistulas and scars. The axillary region is one of the most frequently affected areas. The objective is to evaluate a series of patients with HS in the axillary region who underwent extensive surgical excision and reconstruction with a lateral thoracic fasciocutaneous flap. METHODS: A retrospective analysis of the medical records of patients who underwent treatment between 2010 and 2012 was conducted. RESULTS: Ten patients were operated, of whom two had bilateral involvement, totaling 12 procedures. The mean progression time before the surgical indication was 38 months. The mean defect size after the resection was 10 x 9 cm. The mean size of the flaps was 15 x 10 cm. With regard to early complications, two cases of dehiscence (axillary region) and one case of partial epitheliolysis (distal segment of the flap) were observed. CONCLUSION: We observed that dissection of lateral thoracic fasciocutaneous flaps is not technically difficult and does not present significant functional or aesthetic sequelae in the donor area, making it a reliable and versatile option for reconstruction of larger axillary defects.

Surgical treatment of hidradenitis suppurativa with anterior and posterior lateral thoracic fasciocutaneous flaps / Tratamento cirúrgico de hidradenite supurativa com retalho fasciocutâneo torácico lateral anterior e posterior

Introduction: Hidradenitis suppurativa (HS) is a chronic, multifactorial, and often recurrent bacterial infection, affecting the skin and subcutaneous tissues. However, complete HS resolution can be achieved through surgical treatment. A series of patients with HS complications is described herein, along with their evolution and complications after complete axillary surgical resection and lateral thoracic fasciocutaneous flap rotation. The evaluation of associated affected areas is also reported. Methods: Between 2009 and 2014, 6 patients with an average age of 25.5 years (range: 15 to 35 years) underwent surgery for the treatment of HS. All patients had long-standing, chronic axillary lesions that were refractory to non-surgical treatment. Results: Six patients with HS (2 males and 4 females) underwent surgery. The average follow-up period was 16 months (range: 4 months to 5 years). Complete resolution was achieved and no HS recurrence was observed. Bilateral resection was performed in 4 cases, and unilateral resection in 2. Five patients also had inguinal involvement, and 3 had surgery concurrent with the axilla. Five patients had partial dehiscence and serosanguinous discharge, followed by complete scar formation by second intention healing. Conclusion: Surgery is often the most appropriate and definitive treatment for HS. The lateral thoracic fasciocutaneous flap technique is associated with high success rates in this patient population.

Introdução: A hidradenite supurativa (HS) é uma infecção bacteriana crônica, multifatorial e frequentemente recorrente na pele e nos tecidos subcutâneos. No entanto, a resolução completa pode ser conseguida por meio de cirurgia. É descrita uma série de pacientes com complicações de HS, sua evolução, as complicações após a ressecção cirúrgica completa axilar e a rotação de retalho fasciocutâneo torácico lateral, além da análise das áreas acometidas associadas. Métodos: Entre 2009 e 2014, seis pacientes com idade entre 25,5 anos em média (intervalo: 15-35) foram submetidos à cirurgia para HS. Todos os pacientes apresentaram lesões de longa data axilares crônicas refratárias ao tratamento clínico. Resultados: Seis pacientes com HS (dois homens e quatro mulheres) foram submetidos à cirurgia. O período de acompanhamento foi de 16 meses, em média (intervalo: 4 meses - 5 anos). A resolução completa foi alcançada e nenhuma recorrência foi observada. A ressecção foi bilateral em quatro casos e unilateral em dois. Cinco pacientes apresentaram lesão inguinal, das quais três foram operadas no mesmo tempo cirúrgico. Cinco pacientes apresentaram deiscência parcial e descarga serossanguinolenta, seguida de cura completa após cicatrização por segunda intenção. Conclusão: A cirurgia é frequentemente o tratamento definitivo mais adequado para a HS. A técnica de retalho fasciocutâneo torácico lateral está associada a altas taxas de sucesso nesta população de doentes.

Colgajo paraescapular perforante para tratamiento de la hidradenitis axilar grave / Parascapular Perforating Flap to Treat Severe Axillary Hidradenitis Suppurativa

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[Expedience of application of a dietic therapy in treatment of purulent-septic diseases of soft tissues].

The results of investigation of the dietotherapy impact on the course of purulent-septic process in soft tissues were analyzed. There were operated 58 patients, to 38 of them a certain diet was prescribed. Immediate impact of the diet therapy on the wound process course was established, what was demonstrated by reduction of duration of the earning capacity loss in patients, who have followed a special diet, by 2.58 days.

[Negative pressure therapy in the loss of perineal substance]. / La thérapie par pression négative dans les pertes de substance périnéale.

Over the last ten years, negative pressure therapy has played a major role in the treatment of complex perineum wounds resulting from infection, trauma or cancer.The use of instillation has enabled its use to be extended to certain particularly difficult situations. It is also used routinely in support of dressing techniques for less complex wounds.

Uso do retalho toracodorsal para tratamento de hidradenite supurativa / Use of the thoracodorsal flap for the treatment of hidradenitis suppurativa

INTRODUÇÃO: A hidradenite é uma doença cutânea crônica, que acomete as regiões que abrigam as glândulas apócrinas. Tem uma prevalência estimada de 1% da população, com predileção pelo sexo feminino. MÉTODO:LMN, 48 anos, sexo feminino. Ao exame, a paciente apresentava nodulações palpáveis, coalescentes, dolorosas e uma área de fibrose e retração cicatricial circunjacente em ambas as axilas, principalmente em axila esquerda. Submetida a exérese ampla das lesões em axila e região torácica esquerda, sendo necessária a realização de um retalho fasciocutâneo de rotação, habitualmente usado em pacientes submetidas à quadrantectomia lateral. RESULTADOS: Obteve-se um resultado estético satisfatório associado à preservação dos movimentos. CONCLUSÃO:Apesar de existirem poucos casos relatando o uso do retalho fasciocutâneo toracodorsal lateral, essa técnica mostrou ser excelente alternativa na reconstrução axilar, devido à facilidade de ressecção, boa cobertura da área receptora além de um resultado estético satisfatório.

INTRODUCTION:Hidradenitis suppurativa is a chronic skin disease that affects the regions harboring the apocrine sweat glands. It has an estimated prevalence of 1% of the population and a preference for the female sex. METHOD: LMN, a 48-year-old female patient, presented, on examination, palpable, coalescent, painful nodules and a circumjacent area of fibrosis and scar retraction in both axillae, mainly in the left axilla. She was subjected to wide excision of the lesions at the axilla and left thoracic region, with a need for a rotational fasciocutaneous flap, usually used in patients who undergo lateral quadrantectomy. RESULTS: A satisfactory aesthetic result was attained, together with the preservation of movements. CONCLUSION: Although there are few reported cases of the use of the lateral thoracodorsal fasciocutaneous flap, this technique is an excellent alternative in axillary reconstruction, owing to the ease of resection, good coverage of the receiving area, and the satisfactory aesthetic result.

Perineal reconstruction with local flaps: technique and results.

BACKGROUND: Wide excision of perineal lesions, often including the entire anal canal, may be necessary for benign and malignant conditions. Closure of these large defects is challenging, especially when continence is a goal. The aim of this study was to assess our experience with local flap closure of large perineal defects. METHODS: From 1994 to 2009, 20 patients underwent wide perineal and/or anal canal excisions and reconstruction using local flaps. Mean age was 45 years (range 20-65 years), 13 were male, and 8 (40 %) were immunocompromised. Primary indications included anal or perineal squamous cell carcinoma-(n = 12), Buschke-Lowenstein tumor (n = 3), and anal intraepithelial neoplasia (n = 3), hidradenitis, stenosis, ectropion, and traumatic cloaca repair (n = 1 each). Primary procedures included wide local excision of large neoplastic lesions-(n = 15) (mean size 10 cm, range 5-18 cm), abdominoperineal resection (APR) (n = 2), perineoplasty with sphincteroplasty-(n = 1), and others-(n = 2). All were reconstructed with bilateral local flaps (V-Y 18, S 2). Thirteen had complete excision of the anal canal to the anorectal ring preserving the sphincters. Six (30 %) had ostomies; 2 with APR and 4 temporary. RESULTS: There were no perioperative deaths. Mean hospital stay was 4.2 days. Follow-up averaged 35 months (range 3-87 months) in survivors. Five patients died during follow-up; 2 of complications of acquired immune deficiency syndrome (AIDS) and 3 of cancer (2 treated palliatively). Wound dehiscence occurred in 6 (30 %) patients: in 3 cases, this was minor dehiscence and healed quickly; in 3 cases, it was major dehiscence and occurred in the 2 radiation/APR patients and in one patient with advanced AIDS. Radiation was the only significant risk factor (P < .05). Twelve of 14 eligible patients with long-term follow-up and an intact anal canal are fully continent, and 2 are partially continent (1 traumatic cloaca; 1 the same as before surgery). CONCLUSION: Local flap reconstruction of the perineum and anal canal is an excellent method of managing large perineal defects. Most heal primarily, even in immunocompromised patients, and continence may be preserved. Local flaps should be avoided in irradiated patients.

Thoracodorsal artery perforator flaps and muscle-sparing latissimus dorsi myocutaneous flaps for the treatment of axillary hidradenitis.

PURPOSE: The purpose of this study was to review a single surgeon's experience with using the thoracodorsal artery perforator (TAP) flap for coverage of axillary defects. METHODS: This is a retrospective review of all flaps performed by the senior author (D.W.L.) after excision of axillary hidradenitis between 2004 and 2010. RESULTS: Nine TAP flaps were successfully performed, whereas 5 muscle-sparing latissimus dorsi (MSLD) myocutaneous flaps were necessary because of the inability to harvest a perforator flap. Overall, this equates to a 64% success rate in harvesting a perforator flap. The mean sizes of the TAP and MSLD flaps were 75 cm (range, 32-120 cm) and 83 cm (range, 48-160 cm), respectively. There were 2 (14%) flaps with wound complications. One patient had recurrent disease requiring debridement. Another patient who underwent the largest of all flaps (MSLD) had donor site and recipient bed dehiscence requiring debridement and skin grafting. This patient also later required flap debulking and Z-plasty for scar contracture. DISCUSSION: Overall, TAP and MSLD flaps can be performed reliably for coverage of axillary defects after excision of hidradenitis. Although not free of complications, they do offer improved results compared to historic attempts at primary closure or skin grafting.

Hidrosadenite da vulva: caso exuberante com resolução cirúrgica / Hidradenitis suppurativa of the vulva: case lush with surgical resolution

Contexto: A hidrosadenite é uma doença cutânea crônica e recorrente, com prevalência estimada de 1% e mais comum no sexo feminino. Apesar de se tratar de entidade há muito tempo conhecida, a dificuldade terapêutica ainda é uma realidade. Relato de caso: Apresenta-se um caso de hidrosadenite em paciente de 49 anos envolvendo os grandes lábios bilateralmente, a qual foi submetida à exérese ampla com fechamento por primeira intenção, obtendo-se excelente resultado terapêutico e estético. Discussão: A hidrosadenite é causa de grande transtorno psicológico e social, com prejuízo na qualidade de vida. As possibilidades terapêuticas variam desde antibióticos tópicos e sistêmicos, medicamentos com ação antiandrogênica, retinoides sistêmicos, imunossupressores e, mais recentemente, os antagonistas do fator de necrose tumoral, o uso de tecnologias como o laser e a terapia fotodinâmica até drenagens intermitentes, exéreses parciais e cirurgia radical. A abordagem cirúrgica ampla com margens, associada à cicatrização por segunda intenção, é a preferida de vários autores, porém, o fechamento primário pode estar indicado em casos selecionados.Conclusões: Apesar dos diversos estudos, ainda não existem tratamentos padronizados e com resposta clínica previsível. Cabe ao médico conseguir individualizar cada paciente na busca do melhor tratamento, baseando-se nas evidências existentes até hoje na literatura.

Surgical technique in pedicled thoracodorsal artery perforator flaps: a clinical experience with 99 patients.

BACKGROUND: The thoracodorsal artery perforator flap is considered a technically difficult flap because of significant anatomical variations in perforator location. The authors' strategy to facilitate the harvest of these flaps includes careful preoperative mapping of perforators and a standardized planning and harvesting technique. The authors evaluated 99 pedicled thoracodorsal artery perforator flaps, with an emphasis on preoperative planning, surgical technique, and analysis of complications. METHODS: Between May of 2000 and October of 2006, 99 patients underwent pedicled thoracodorsal artery perforator flaps in the authors' department. Their charts and postoperative results were reviewed retrospectively. RESULTS: A thoracodorsal artery perforator flap was harvested in 90 cases. The perforators were unsuitable in the other 10 flaps; therefore, a muscle-sparing technique was used (type I or type II). Unidirectional Doppler imaging was used exclusively in 92 percent of cases to map the perforator preoperatively. The average flap size was 20 x 8 cm. Average operative time for flap harvest was 80 minutes. Perforators were located at 8 to 13 cm from the axillary crease (average, 10.8 cm). Major flap necrosis occurred in one case (1 percent). Limited partial or palpable fat necrosis occurred in three cases (3 percent). Seroma formation was not encountered in any of the thoracodorsal artery perforator flaps or muscle-sparing thoracodorsal artery perforator type I flaps. CONCLUSION: Careful preoperative perforator mapping and a standardized approach to flap planning and harvest can significantly reduce the difficulty of executing pedicled thoracodorsal artery perforator flaps.

Manejo práctico de la hidrosadenitis supurativa / Practical management of hidradenitis suppurativa

La hidrosadenitis supurativa (HS) es una enfermedad inflamatoria crónica que suele manifestarse en zonas cutáneas con gran densidad de glándulas apocrinas (axilas, ingles, región perianal, perineal, submamaria, etc.). Suele iniciarse en mujeres durante la pubertad. La etiología de esta enfermedad es desconocida, aunque se considera un defecto primario del folículo piloso. Debemos considerar una serie de factores predisponentes (genéticos y hormonales) y otros desencadenantes controvertidos (obesidad, tabaco, ropa ajustada, etc.) en el diagnóstico de la HS. El diagnóstico es básicamente clínico y es importante tener en cuenta las posibles complicaciones derivadas del padecimiento de esta enfermedad, como la posibilidad de desarrollar lesiones tumorales. El manejo de esta patología comprende diversas pautas: medidas generales (jabones antisépticos, baños templados, etc.), farmacológicas (tópicas, intralesionales y sistémicas), quirúrgicas (cierre directo, cierre por segunda intención, injertos, colgajos, etc.) y otras medidas (láser CO2, radioterapia, etc.). Es importante identificar y tratar cuanto antes esta patología debido a los potenciales problemas físicos y psicológicos en los que puede derivar (AU)

Hidradenitis suppurativa is a chronic inflammatory disease that usually affects areas of the skin with a high density of apocrine glands (axillae, groin, perianal and perineal regions, submammary area, etc). It usually appears in women during puberty. The etiology of the disease is unknown, although it is thought to be a primary defect of the hair follicle. When diagnosing hidradenitis suppurativa, a number of genetic and hormonal predisposing factors should be considered alongside other putative triggers, such as obesity, smoking, and tight clothing. Diagnosis is essentially clinical and it is important to bear in mind the possible complications associated with the disease, such as the development of tumors. Management of the disease includes general measures (antiseptic soaps, warm baths, etc), pharmacological therapy (topical, intralesional, and systemic), surgery (direct closure, second-intention healing, grafts, flaps, etc), and other measures (carbon dioxide laser, radiation therapy, etc). It is important that the disease be diagnosed and treated as soon as possible given the potential physical and psychological problems that it can generate (AU)

Hidrosadenitis axilar severa: opciones quirúrgicas / Severe axilar hidrosadenitis: surgical options

En los cuadros severos de hidrosadenitis ( hidradenitis supurativa) axilar con un área infeccioso inflamatoria extendida y retracciones secundarias que limitan la capacidad funcional articular del hombro, la mejor solución pasa por el desbridamiento radical de todo el área afecta y su posterior cobertura con tejido de buena calidad. Los colgajos locales basados en perforantes torácico laterales y toracodorsales con distintos diseños y los derivados de la arteria circunfleja escapular con la Variante bilobulada escápulo - paraescapular para los casos extremos, ofrecen posibilidades locales de muy buena calidad para defectos de todas las dimensiones. Se presentan cinco casos de hidrosadenitis axilar mostrando las posibilidades de cobertura con los colgajos citados (AU)

Hidrosadenitis supurativavulvar / Vulvar suppurative hidrosadenitis

Presentamos un caso de una mujer con hidrosadenitis perianal y vulvar, de 20 años de evolución intervenida en múltiples ocasiones que tuvo que someterse a vulvectomía. La hidrosadenitis supurativa es una enfermedad inflamatoria supurativa crónica que afecta a las glándulas sudoríparas apocrinas de la axila, área genital, mamas y otras localizaciones; es rara antes de la pubertad y tiende a declinar tras la menopausia (AU)

Aquaporins and the surgeon: cautionary tales.

Nephrogenic diabetes insipidus (NDI) presents an uncommon but formidable clinical challenge in the surgical patient. Two recent cases of NDI with differing aetiology are presented. These cases and a review of the literature illustrate well the diagnosis, fluid and electrolyte imbalances seen and the strategy of treatment required in the post-operative setting. The central role of the recently discovered aquaporin channels in this condition is briefly outlined. Nephrogenic diabetes insipidus has a diverse aetiology and many of the hazards of the condition are peculiar to the surgical setting. The importance of management in a high dependency environment is highlighted.

Long-term results of wide surgical excision in 106 patients with hidradenitis suppurativa.

BACKGROUND: Hidradenitis suppurativa (acne inversa) is a chronic recurrent disorder characterized by abscessing inflammation, fistulating sinus tracts, and scarring. Predilection sites are the intertriginal regions. The severe course of the disease demands an early and curative treatment. OBJECTIVE: The aim of this study was to review the effect of radical surgical excision concerning cure rate and potential complications within a large group of patients. METHODS: We analyzed data for 106 patients suffering from hidradenitis suppurativa treated during the period 1980-1998. The mean duration of the disease was 7 years. In about 90% of the cases, two or more sites were affected. Inguinal (70.8%) and axillary regions (61.3%) were most commonly involved. All patients were treated by radical wide excision using intraoperative marking of sinus tracts with methylviolet solution. The method of reconstruction depended on the size and location of the defect. Median postoperative follow-up time was 36 months. RESULTS: The overall complication rate was 17.8%. Most of these were minor complications such as suture dehiscence, postoperative bleeding, and hematoma. Wound infection occurred in only 3.7% of patients. The rate of recurrence within the operated fields was 2.5%. There was no relation between the surgical method of reconstruction and the rate of recurrence. Recurrence was related to the severity of the disorder. CONCLUSION: Our results confirm early radical excision as the treatment of choice for hidradenitis suppurativa. Using intraoperative color-marking of sinus tracts, the recurrence rate is minimal. The method of reconstruction has no influence on recurrence and should be chosen with respect to the size and location of the excised area.

Carcinoma verrucoso sobre hidrosadenitis supurativa perianal. Presentación de un caso y revisión bibliográfica / Verrucous carcinoma complicating perianal hidradenitis suppurativa. Case report and literature review

La hidrosadenitis supurativa es una enfermedad inflamatoria crónica que afecta a las glándulas apocrinas. Al igual que en otras enfermedades inflamatorias crónicas de la piel pueden producirse cambios degenerativos. El carcinoma escamoso es la neoplasia maligna descrita con más frecuencia siendo excepcional el hallazgo de su variedad bien diferenciada denominado carcinoma verrucoso. Desde 1988, en nuestro hospital se han intervenido 44 pacientes diagnosticados de hidrosadenitis supurativa, de los cuales 15 presentaban una forma masiva de la enfermedad. Durante este periodo tan solo un paciente atendido en nuestra unidad de coloproctología por afectación perianal presentó degeneración maligna hacia un carcinoma verrucoso. Presentamos este caso y comentamos las peculiaridades clínicas y terapeúticas de esta situación tan poco frecuente (AU)

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