Rapid healing of chronic ulcerations and improvement in range of motion after fractional carbon dioxide (CO2) treatment after CO2 excision of hidradenitis suppurativa axillary lesions: A case report.

Introduction

Hidradenitis suppurativa (HS) is a debilitating condition characterized by recurrent abscess formation, fistulas, and scarring that frequently involve the axillae, gluteal folds, groin, and the inframammary region. The disease process and subsequent surgical interventions can lead to significant scarring and functional impairment. HS and scarring are both associated with damaging psychological effects. Traditional surgical excision and carbon dioxide (CO2) laser excision with healing by secondary intention are reported to be effective methods of treatment for advanced HS but can lead to scar formation.2, 3 In a study in which 61 consecutive patients underwent treatment for HS using CO2 excision in 185 sites, there were 2 episodes of recurrence with follow-up between 1 and 19 years postoperatively. Here we report the first case of a patient whose scars, restricted mobility, and chronic ulceration secondary to CO2 laser excision were treated successfully with fractional CO2 laser.

Case report

The patient is a 21-year-old obese African-American female with a history of stage III HS located in the bilateral axillae, labia, groin, and upper medial thighs. She underwent failed treatment with spironolactone, oral contraceptive pills, multiple courses of oral antibiotics, topical benzoyl peroxide, and topical clindamycin. After partial response to 3 neodymium-doped yttrium aluminium garnet laser treatments, the patient underwent a series of 6 additional sessions. After completion, physical examination found numerous interconnected sinus tracts, nodules, and extensive scarring in the left axilla (Fig 1). The decision to pursue surgical intervention was made, and she subsequently underwent CO2 laser excision to the left axilla, as this was the most severely involved area. The patient tolerated the procedure well, and her wound was left to heal by secondary intention (Fig 2).

Fig 1

HS of the left axilla. There are multiple interconnected sinus tracts, nodules, and significant scarring.

Fig 2

HS of the left axilla after CO2 excision.

Recovery from CO2 laser excision was complicated by chronic ulceration and scar contracture, which caused restricted range of motion. When the patient performed daily tasks, she would notice worsening ulceration, but with decreased movement of the upper extremity, the lesions would begin to heal. Nine months postoperatively, physical examination found 2 nonhealing erosions in the left axilla and scar contracture (Fig 3). We hypothesized that high tension in this area was contributing to the chronic ulcerations. As treatment, the patient underwent fractional ablative CO2 laser treatment to the palpable firm and contracted areas surrounding the ulcerations in the left axilla.

Fig 3

HS of the left axilla 9 months after CO2 excision with two chronic nonhealing ulcers.

The patient was treated with 4 sessions separated by 5 to 6 weeks with the following laser parameters: 50 J of pulse energy, 5% density, and nominal 120-μm spot size with a fractional CO2 laser (Lumenis, Inc, Yokneam, Israel). Pretreatment anesthesia with forced cool air was used. The area was dressed with petroleum jelly, and there were no reported adverse events. By the third treatment, the erosions had mostly healed with the exception of one area of granulation tissue, but the textural appearance of the scar was improved. By the fourth and final treatment, the erosions were completely healed with only one area of hypertrophic scar on the lateral aspect of the left axilla. It should be noted that since the CO2 excision, the patient lost 14% of her body mass. We hypothesize that because of improvement in disease and mobility the patient was able to participate in more physical activity. Sixteen months postoperatively the patient has no evidence of HS recurrence, no deficits in range of motion, and an improved texture and appearance of the scar (Fig 4).

Fig 4

HS of the left axilla after CO2 excision and 4 sessions of fractional CO2 laser treatment. The ulcers have resolved with improved textural appearance of the scar, and the patient has improved range of motion.

Discussion

Currently, most treatments for HS focus on treating inflammatory lesions rather than any scarring and resulting debility. There have been many recent advances in scar treatments, particularly with laser intervention. In 2004, Manstein et al first reported the concept of fractional photothermolysis for skin restoration. This technique involves the use of heat to create microscopic columns of injury where interspersed areas of healthy, noninjured tissue serve as a reservoir of cells for wound healing. The thermal injury leads to upregulation of procollagen messenger RNA, several matrix metalloproteinases, and cytokines, which are involved in the wound healing process. Since the development of this technique, fractional CO2 laser has shown efficacy in the treatment of many different types of scars including atrophic acne scars, mature burn scars, restrictive scars, and hypertrophic scars.7, 8

Deep FX settings were chosen for this treatment because of a modest immediate photomechanical release of tension in some restrictive scars, which is seen after fractional laser tissue ablation. It is hypothesized that this reduction of tension surrounding the edges of the ulcer directly contributed to the rapid healing in our patient. Additionally, in mature burn scars there is an increase in type III collagen (seen in fetal and scarless healing) after treatment with fractional laser, likely leading to an improvement in scar appearance, tension, and texture.

Recently, Krakowski et al reported a case of a pediatric patient whose HS was controlled with medical management. However, she experienced psychological distress over the appearance of cribriform scarring in the inframammary region. The scarring was treated with 2 sessions of fractional CO2 laser separated by 2 months, which resulted in reduced erythema, improved texture, pliability, and appearance of the scar.

Although the scarring in these HS patients had different causes, it appears that the fractional CO2 laser has some efficacy in reducing morbidity in HS-related scars. The rapid increase in both range of motion and healing of chronic ulcers in our patient supports previous research on the importance of tension in chronic wounds. The combination of CO2 laser excision with fractional laser treatment for possible scar contracture may make treatment of extensive disease with excision a more acceptable treatment option. However, further prospective studies are needed to determine the role of fractional CO2 laser in the treatment of HS-related scarring.