No se palparon adenopatías ni se observaron otros signos de interés. Download full-size image. Figura 1. Hidrosadenitis supurativa en región axilar derecha. La hidradenitis supurativa es una enfermedad cutánea crónica, inflamatoria, y son más frecuentes en las regiones axilares, inguinales y anogenitales. PDF | Hidradenitis suppurativa is a clinically defined disease that causes Although the examples shown here are of hidradenitis suppurativa of the axillary area, .. Downloaded from oblilerixhea.cf at KAISER PERMANENTE on January 11,
|Language:||English, Spanish, German|
|Distribution:||Free* [*Registration Required]|
Hidradenitis suppurativa (Hurley's Staging II) in the left axilla. +8 Download full- text PDF. Content . excision in the axilla, inguinal region, gluteal region,. trunk. Colgajo paraescapular perforante para tratamiento de la hidradenitis axilar grave . Visits. Download PDF. J. Tercedor-Sánchez, J.M. Ródenas-López. Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease presenting with painful Download Fulltext PDF .. undergoing wide resection of axillary hidradenitis with reconstruction by Limberg transposition flaps.
Although little is known about the mechanism, abnormal Notch signaling appears to promote the development of nodules and lead to inflammation in the skin. Hurley separated patients into three groups based largely on the presence and extent of cicatrization and sinuses. It has been used as a basis for clinical trials in the past and is a useful basis to approach therapy for patients.
These three stages are based on Hurley's staging system, which is simple and relies on the subjective extent of the diseased tissue the patient has. Hurley's three stages of hidradenitis suppurativa are:  Stage Characteristics I Solitary or multiple isolated abscess formation without scarring or sinus tracts A few minor sites with rare inflammation; may be mistaken for acne.
II Recurrent abscesses, single or multiple widely separated lesions , with sinus tract formation. Frequent inflammation restrict movement and may require minor surgery such as incision and drainage. III Diffuse or broad involvement across a regional area with multiple interconnected sinus tracts and abscesses Inflammation of sites to the size of golf balls, or sometimes baseballs; scarring develops, including subcutaneous tracts of infection — see fistula.
Obviously, patients at this stage may be unable to function. Sartorius staging system[ edit ] The Sartorius staging system is more sophisticated than Hurley's. Sartorius et al. This classification allows for better dynamic monitoring of the disease severity in individual patients. Whether these pathogens are the cause of the lesions or are secondary infectious agents, these findings support targeted antimicrobial treatment of HS. Hidradenitis suppurativa HS , also known as acne inversa and Verneuil disease, is a chronic disease of the apocrine gland—bearing areas of the skin 1.
It is therefore of major public health concern. HS usually begins after puberty; the clinical severity of the disease varies among patients. Most patients have a mild form of the disease, manifested as painful large and deep-seated nodules.
In contrast, patients with severe HS have chronic, painful, suppurating lesions that persist for years. Chronic lesions usually involve multiple areas connected by inflamed and suppurating sinus tracts surrounded by hypertrophic scars.
The pathophysiology of HS is mostly unknown and probably multifactorial, including genetic, infectious, hormonal, and immunologic factors 3. Approximately one third of HS patients have a familial history of HS.
Familial HS is transmitted with a dominant autosomal inheritance pattern, and mutations in the gamma secretase genes have been associated with a subset of familial cases 4 , 5. The current hypothesis is that the HS primary event is a hyperkeratinization of the follicular infundibulum, followed by follicular occlusion, dilatation and rupture; the spread of bacterial and cellular remnants would trigger the local inflammatory response 3.
Previous microbiological studies found a wide range of bacteria sporadically associated with HS lesions: Staphylococcus aureus, Streptococcus agalactiae, coagulase-negative staphylococci, milleri group streptococci, anaerobes, and corynebacteria 6 — 8.
Because of these confusing microbiological observations and the rapid relapse of HS lesions after standard antimicrobial drug treatments, bacteria were considered to be contaminants of primarily inflammatory lesions.
Recently, the rifampin-clindamycin drug combination was reported to substantively improve HS lesions 9 , 10 , and our research team showed that complete healing of HS lesions can be obtained by using the rifampin-moxifloxacin-metronidazole drug combination These findings suggest that suppurative lesions associated with HS may be of infectious origin.
In this study, we performed an extensive microbiological study of HS lesions and identified 2 main profiles of opportunistic bacterial pathogens associated with HS lesions. These pathogens are commonly isolated from skin and soft tissue infections and are known to be sensitive to antimicrobial drug treatments used to obtain improvement or remission of HS lesions.
In this study, we performed a microbiological analysis of all HS lesions sampled from patients who consulted for the first time in our center for active HS during June —February Table 1. We excluded patients who received systemic or topical antibiotic drugs during the month before sampling. The clinical severity of lesions was assessed and designated by the same physician using the clinical severity staging of Hurley Briefly, according to Hurley, stage 1 lesions correspond to nodules or abscesses, single or multiple, without sinus tracts or hypertrophic scars.
Stage 2 lesions are single or multiple but nonconfluent lesions with sinus tracts and formation of scarring. Stage 3 lesions correspond to diffuse or nearly diffuse involvement of multiple interconnected sinus tracts or abscesses across an entire area. Transcutaneous samples were collected only from patients who gave informed consent.
Such samples were obtained from all closed abscesses or nodules and were also recommended for suppurative lesions. For suppurative lesions, we also suggested collecting purulent drainage by swab and collecting an additional control specimen at a 5-cm distance from the lesion, considering that biopsy may fail to reach the infectious site. No transport medium was used for punch biopsy specimens and purulent drainage collected by puncture.
Samples were sent to the laboratory within 1 hour after sampling. Bacterial Cultures and Identification Methods To grow anaerobic bacteria, we homogenized biopsy samples using a sterile porcelain mortar in 0. Purulent drainage and swab specimens were directly discharged in 0.
Columbia agar plates were incubated anaerobically for 2 weeks. Cultures were analyzed at days 2, 7, and 15 by the same physician throughout the study.
Anaerobic cultures were considered positive when the abundance or diversity of the bacterial culture was increased under anaerobic conditions.
Plates were streaked by using the 4-phase pattern for isolation of predominant colonies. A maximum of 10 colonies per sample was identified by matrix-assisted laser desorption—time-of-flight mass spectrometry by using the Andromas system When no identification was obtained, the 16S ribosomal RNA gene was sequenced. Altogether, bacterial isolates were identified from the culture-positive samples.
Bacterial species were grouped in 12 categories Technical Appendix Figures 1—5. Bacterial Metagenomics To investigate more precisely the anaerobic microflora and to decipher whether nonculturable species could be associated with HS lesions, we performed a metagenomic study on 6 consecutive samples including 1 Hurley stage 1 abscess and 5 chronic suppurating lesions.
An average of 4, quality sequences 2,—7, sequences were obtained from each sample. One of the flaps developed infection and wound dehiscence, with a need for hospital readmissions on the 15th postoperative day, with surgical approach for cleaning and debridement of devitalized tissue, with new advances and repositioning of the flap.
The culture-guided antibiotic was modified, and the patients were discharged after 3 days. Small skin dehiscence solution of continuity up to 5 mm of skin with exposure down to subcutaneous plane occurred in the distal ends of three parascapular flaps, which were healed without prejudice to the result by second intention.
Total loss of parascapular flap did not occur in any case. The donor areas evolved with enlargement of the scars, with a need for revision according to the patients' aesthetic complaint in all the cases Table 1. The patients reported an improvement in abduction of the upper limbs, with gain of amplitude and absence of axillary contracture Figures 4 and 5. Figure 4. Postoperative view of the coverage of the axillary defect and the donor area with the left parascapular flap.
Figure 5. Posterior view of the donor areas of the parascapular flaps, with full abduction of the upper limbs. In moderate and serious forms, beyond the measures mentioned, surgery becomes necessary to reduce morbidity and recurrence9. Weight loss and smoking cessation are important measures to decrease the severity and recurrence of the disease.
Surgical treatment is recommended in rebounding chronic HS. Hurley scale helps determine the degree of tissue resection. Regarding methods of resection for axillary disease, excisions may be locally limited to the hairy edge, or may be radical, consisting of a 2-cm margin from the hairy edge and deepening to the muscle fascia As for the forms of coverage of the defect in the axillary region, primary synthesis, healing by secondary intention, and skin and flap grafting are employed.
The first three procedures are the most frequently used. The flaps are used for more-complex defects, with better reconstruction quality Grafting, despite being commonly used, is associated with high rates of infection, necrosis, and contracture The flaps are classified as local, regional, and free. Among the local flaps, Limberg, propeller and transposition flaps deserve highlight. The anterolateral thigh flap is the most widely used free flap in axillary reconstruction.
Nonetheless, it is associated with a trapdoor effect The latissimus dorsal muscle, scapular, thoracodorsal perforating artery TDAP , and parascapular flaps are local flap alternatives.
Literature reported that the latissimus dorsi muscle flap, despite enabling primary closure of the donor area, often evolves with distal necrosis Moreover, it is a poor alternative for breast reconstruction. The fasciocutaneous scapular flap is thick, requiring the refinement of the thickness in the fat layer to be more adequate for the region and anterior chest region The TDAP flap requires a more improved dissection technique and is based on smaller-caliber vessels.
Nevertheless, it is a good alternative Described in , the parascapular flap is a fasciocutaneous flap based on the descending branch of the circumflex scapular artery, which is a subscapular branch. It may be used as a pedicle flap or freely, as it has a safe and reliable pedicle. It is located in the lateral portion of the scapula, providing for coverage of extensive defects, and its donor area can be closed primarily. This is our choice in the reconstruction of defects with chronic axillary HS because it allows for similarities in color, texture, and skin thickness between the recipient and donor areas Figures 6 to 8.