Hidradenitis suppurativa (HS), also called Acne inversa or Verneuil’s disease, was first described by Velpeau in 1839. Verneuil named the condition and associated it with sweat glands in 1854. It is in 1939 that the relation with apocrine glands was described by Brunstig [1] [2]. It is a chronic and recurrent condition arising in apocrine gland bearing skin in the body folds, especially the groin and the armpit, causing painful abscesses and scarring. At the beginning, it presents as subcutaneous nodules. Later, those nodules may coalesce to form dermal painful abscesses or rupture leading to purulent and offensive smelling discharge. Finally, the abscesses heal with a lot of fibrosis, dermal contractures and skin induration. The characteristic features of HS are double comedones (blackheads with multiple apertures communicating below the skin), sinus tracts (resulting in the reepithelization of hair follicles after their rupture following occlusion) that shelter bacteria of foreign bodies and abscesses [1] [3].

The diagnosis of HS is clinical and requires no biopsy or other analysis and is based on the frame of recurrent/chronic disease, failure to heal completely with antibiotics, multifocal distribution, sinus formation, scarring and dermal contractures, presence of double comedones, multiple open comedones, nodules, papules, tenderness of lesions and purulent discharge [4] [5]. The treatment alternatives for HS include general and topical antibiotics (Tetracyclin, Clindamycin), retinoids, immunosuppressants, antiandrogens and surgery [6]. In 2017, Deckers undertook a study on a sample of 84 HS patients. A total of 253 surgical procedures were performed. The recurrence rate was as high as 37.6% after a mean follow up time of 3 years while the total remission rate was 49 years. The main recurrence factor was location in anogenital area [7]. On the other hand, Wolkenstein et al. studied the quality-of-life impairment in 61 HS patients. They found that the said impairment was much greater than in any other dermatological condition [8].

The occurrence of HS in the groin and perineum is accompanied with lots of pains, social embarrassment. Compared to other skin lesions, HS impacts most negatively on the quality of life [9]. The present study is a retrospective review of severe HS of female perineum and genitalia surgically treated with focus on the outcomes and impact on the quality of postoperative life.

We carried out a retrospective review of the files of 55 women operated for severe perineal or genital HS in Henri Mondor Teaching Hospital in Créteil between December 2017 and June 2019. The mean age at surgery was 29.78 years. 96.4% of the patients had localized or wide surgical excision and 3.6% an incision and drainage. We recorded a 49.1% rate of recurrence associated with overweight, location on groin, localized excision, total excision, healing via secondary intention and disability due to HS. 83% of the patients were satisfied with the surgery and would recommend it or accept revision surgery while the post-surgery composite index for sexual satisfaction was 18.51 meaning no pathologic sexual disorder.

The etiology of HS is still controversial. But the understanding of the disease has changed over time. After an initial theory by Verneuil that incriminated sweat glands for over a century, Brunstig suggested that apocrine glands be blamed for it [1]. Many etiopathogenic factors have since been reported: genetic (one form has autosomal dominant transmission), endocrinologic (high androgen levels), environmental (shaving, friction), bacterial, pharmacological (lithium), obesity and smoking [1] [12] [13].

This disease usually starts in the second or third decade and is rare after menopause. Its prevalence ranges from 0.00033 in clinical data to 4.1% in pathological reports [1] [14]. It occurs predominantly in women with a sex ratio ranging from 2 to 5 women for a man that is yet to be explained [14]. It has no racial predilection [15] [16] [17] though some authors in limited studies have reported African Americans and Caribbeans to be more prone to develop HS [18] [19].

The diagnosis of HS is clinical. Its differential diagnosis is done with some conditions including but not limited to Chron’s disease, granuloma inguinale, cellulitis, anal fistula, lymphadenopathy and tuberculous abscess [1] [20].

Hurley was the first to propose a staging system for HS that was surgery-oriented [21]. Later on, Sartorius proposed another classification, more suited for clinical trials and their outcomes [22]. More recent staging systems have been proposed but are not yet widespread. They include Physician Global Assessment (PGA) and Hidradenitis suppurativa Clinical Response (HiSCR) [3].

As the disease worsens over stages, it not only destroys patients tissues but also take away their quality of life especially because of pain, discomfort, offensive odors, multiple or long medical leaves, fear of social interactions, low self-esteem, stigmatization and work disability [1] [23] [24] [25].

The treatment of earlier stages HS is behavioral and medical and include education of patients to encourage self-watch and management, wearing of loose clothes to avoid friction in intertriginous folds, weight loss, tobacco cessation and cleanliness to reduce odor, topical treatment, intralesional corticosteroids and antibiotics (Doxycycline, tetracycline or Clindamycin) [1] [3] [13]. In past years, radiotherapy was used in earlier stages with some success [1]. Severe disease requires more aggressive treatments like Carbon dioxide or YAG evaporation of diseased tissues and radical surgery. In 2015, an expert panel issued European Guidelines for the treatment of HS/acnea inversa recommending that HS be treated based on its subjective impact and its objective severity using surgery to cure locally recurrent lesions while medical therapy (including antibiotics and immunosuppressants) in combination with surgery be used for wide spread lesions [12] [13].

Recurrence is a well-known feature of HS. Our recurrence rate on same site is (23.6%). Ulrich et al. found a recurrence rate of 12.5% in a German series of 84 patients, significantly higher in heavy smokers [26]. Deckers et al. reported 37.6% recurrence rate after a 3-year long follow-up in a series of 84 patients who underwent 253 procedures [7]. Other authors report lower recurrence rates. The difference lies in the heterogeneity of the samples since the initial severity, patients’ comorbidities, location of the disease, extent of the involvement and surgical techniques are important determinants of recurrence [1] [12]. In fact, Mehdizadeh et al. in a meta-analysis and review reported that wide excision is the best surgical technique whenever possible as it lowers the recurrence rate [27]. However, there is no consensus on the preferred surgical technique and it is not always possible to perform a wide excision in some locations like groins, buttocks perineum and genitalia [1] [6].

We registered a post-surgical satisfaction rate of 83%. Those patients said would recommend surgery to others or undertake revision surgery in case of failure or recurrence. The retrospective nature of the study did not permit to get the preoperative assessment of the quality of life. However the postoperative survey revealed an overall improvement of the quality of life through abovementioned high satisfaction rates. Kouris et al. in a study compared 94 HS patients with 94 controls and found that the cases had statistically significantly higher anxiety, depression, loneliness and social isolation scores than their control counterparts [23]. In the same vein, Alavi et al. found that patients with high odor had a greater quality of life impairment and concluded that malodor was a symptom of HS that significantly impairs the QoL of affected persons [28]. In this study sample, only 13.2% of patients were not satisfied.

Regarding sexual life, all the compartments of sex response were adversely affected by HS, but there was a general postoperatively satisfaction since the composite index for SFSI was within normal range. This is comprehensible since our sample included only severe cases that already faced the worst symptoms of HS (purulent discharge, malodor, disability). Janse et al. surveyed 300 patients of HS on their sexual health and QoL and reported a diminished QoL and sexual health in this population according to FSFI, ASEX and IIEF scores [24]. Furthermore, sexual life was associated with QoL in women but not in men and female gender and late onset was associated with poorer sexual function.

The limitation of this study is its retrospective design that did not allow us to properly assess preoperative sexual and life quality. That information was not systematically recorded at that time.

We retrospectively reviewed the files of 55 women with severe HS operated between December 2017 and June 2019. Localized and wide excisions yielded good cosmetic and functional results illustrated by high satisfaction rates on assessment of post-surgical and sexual quality of life. Recurrence rate was high since total excision is difficult to perform in groin and ano-genital areas.

Chronicity and recurrence make HS a psychologically hard-to-live condition. Therefore, management should be holistic and multidisciplinary involving dermatologists, psychologists, gynecologists, sexologists, and any other specialist when necessary. More studies need to be carried out with larger samples to better understand its etiology and characterize the patient population.

DS, CT and BH designed the study. DS recruited the subjects, analyzed the data and drafted the manuscript. CT, BH and JPM corrected the manuscript. DS, CT, BH and JPM all accepted the final version.

To all the patients who accepted to return our questionnaire, without whom this study wouldn’t have been done.

We received no funding or grant for this study.

The authors declare no conflict of interest.

Sawan, D., Touboul, C., Hersant, B. and Meningaud, J.P. (2021) Surgical Management of Severe Hidradenitis Suppurativa in Women: Outcome and Quality of Life Assessment. Open Journal of Obstetrics and Gynecology, 11, 1425-1436. https://doi.org/10.4236/ojog.2021.1111132

ASEX: Arizona Sexual Experience scale

FSFI: Female Sexual Function Index

HiSCR: Hidradenitis Suppurativa Clinical Response

HS: Hidradenitis suppurativa

IIEF: International Index of Erectile Function

PGA: Physician Global Assessment

QoL: Quality of life

SSQ: Surgical satisfaction questionnaire