Surgical treatment of acne inversa at the University of Heidelberg

Acne inversa is a chronic, recurrent, fistula- and abscess-forming disease formerly called hidradenitis suppurativa, pyodermia fistulans sinifica or acne tetrade. Like in acne vulgaris, the main pathogenetic mechanism consists of follicular occlusion with subsequent inflammation of the pilosebaceous unit. The aim of this study was to determine the outcome of the surgical procedure and wound management applied in our clinic, to identify pathogenetic factors contributing to the course of the disease and to evaluate acne inversa patients with special respect to clinical manifestations, histology and bacterial colonisation. We evaluated 66 patients with acne inversa, treated in our clinic between 1987 and 1999. Radical excision combined with open wound healing was performed in all patients. We found both sexes equally frequent, mean age at disease onset was 22.5 years, mean age at presentation was 34.7 years, mean duration of disease was 11 years. 55% of patients also had a family history of acne inversa. 80% of patients were smokers. 80% of males suffered also from pilonidal sinus compared to 57% of females, while only 45% of males had inguinal or perianal lesions compared to 90% of females. There was no correlation of disease activity or prevalence with other diseases, especially not with atopic dermatitis, Crohn's disease or colitis ulcerosa. Histologically most patients showed follicular occlusion, fibrosing granulomatous dermatitis and formation of sinus tracts lined by pathologically differentiated epithelia. Staphylococcus aureus was frequently found pre-operatively. Minor recurrent disease on operated sites was noted in 23% of patients, but only 5.75% of patients required further surgical intervention. Over 90% of patients were satisfied with functional and esthetical result. Since the inflammatory process clearly emerges from the pilosebaceous unit, the aim of surgical treatment has to be the elimination of hair follicle bearing skin from the affected intertriginous areas. Radical excision combined with subsequent open wound healing has proven to be a reliable treatment resulting in minimal recurrent disease and satisfactory cosmetic result.