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Case Report

Grafting a spherical hidradenitis-affected scrotal raw area using a sterile glove: a case report describing the Al Lahham technique

Al Lahham, Salim MDa,b,c; Aljassem, Ghanem MDa,; Al-Basti, Habib MDa; Alyazji, Zaki T.N. MDa; Sada, Ruba MD, PM, CPESEd

Author Information
doi: 10.1097/SR9.0000000000000011
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Abstract

Hidradenitis suppurativa (HS) is a chronic inflammatory condition that affects the skin, which is known historically as Verneuil disease1.

The new theories suggest that it is a chronic follicular occlusive disease, not related to sweat glands as the name implies, and the estimated prevalence is 1%–4%2,3.

The usual onset of the disease is between puberty and 40 years of age and the most commonly affected areas are the axilla and the groin4.

It is characterized by the recurrent appearance of papules and pustules that may end up—in the severe form of the disease—with abscesses and pus draining sinuses that heal with rope-like scars.

Treatment options are driven by the severity of the disease, ranging from medical therapy by antibiotics, immunomodulation therapy, and in the most severe and resistant cases the surgical option stands out as the only solution.

In this paper, we report a case of severe HS affecting the axilla and the inguinal region and the scrotum treated surgically. The challenge was how to secure the graft in the enlarged affected scrotum where we used a piece of a sterile glove that was fixed to the graft with sutures.

Case presentation

A 45-year-old man presented to our institute with pain, pimples, and malodourous discharges from the axillary and groin lesion that have been disturbing him for 11 years.

The patient was attending the dermatology clinics where he tried all possible medical treatments including several courses of adalimumab without any benefit.

No other significant medical issues, nonsmoker, nonalcoholic.

On physical examination the patient had scarring with discharging sinuses in both axillary and groin area involving the scrotum. Multistaged surgery was advised for the axilla and then the groin; all the surgical procedures were performed by Dr Salim Al Lahham.

Axilla debridement was done and after 2 weeks, which was reconstructed with lateral thoracic perforator flaps, a period of rest followed to allow maximum healing of the wounds before turning to the inguinal region.

After 4 months, the patient underwent debridement of bilateral inguinal areas and was placed on a course of antibiotics for 10 days, and then underwent reconstruction with bilateral pedicled ALT flaps; the scrotal skin was shaved in the same setting ensuring removal of all sinuses.

As our usual SINGAPORE “pudendal” flap was not an option because of the chronic inflammation in the donor area our best option to cover the scrotal raw area was a split thickness skin graft which was taken from the thigh 1 week later, meshed to X1.5 and fixed on the debrided bed using Vicryl rapid 4-0 sutures.

Our challenge was how to secure the graft in place bearing in mind the big size of the scrotum that is affected by mild lymphedema because of the long-standing HS.

So a circle was designed on a nonpowdered sterile glove and cut, multiple slits were made across the circle to allow for drainage, then the rubber piece was stretched and fixed to the bed margins using sutures all around, where the inner part of the glove is facing the graft surface.

The patient was kept on antibiotics for 1 week as advised by the infectious diseases team; the first dressing of the grafted area was done 6 days postoperation, which showed complete graft intake. The patient was discharged on the seventh day, dressing was continued every other day until complete graft healing was achieved at 14 days postoperation when the patient was seen in the clinic. Clinic follow-up continued monthly and 6 months postop results is shown (Figs. 15).

Figure 1
Figure 1:
Preoperative figure.
Figure 2
Figure 2:
Postoperative figure.
Figure 3
Figure 3:
Postoperative figure.
Figure 4
Figure 4:
Two weeks postoperative.
Figure 5
Figure 5:
Six months postoperative.

The present work is reported in line with the SCARE guidelines 20185.

The paper was submitted to ResearchRegistry with a Research Registry unique identifying number (UIN): researchregistry60816.

Discussion

HS can be classified to mild, moderate, and severe according to Hurley clinical staging system7.

The goals of treatment would be to treat the existing lesions, prevent new lesions, and minimize the psychological morbidity that is associated with the disease.

Treatment options start medically and in the most severe forms that do not respond to medical therapy, surgical treatment is the best approach.

The principle of HS surgery is to widely and extensively debride the affected areas including the skin and subcutaneous fat to minimize recurrence rates that is higher when using conservative surgery8.

Reconstruction follows by primary intension on a later stage when the wounds are clean or by secondary intension which is a long postoperative recovery process9,10.

Reconstruction options would be primary closure, split thickness grafts or local flaps. Watson reported high recurrence rates after primary closure compared with other modes of reconstruction11,12.

Our case represents a severe form of HS that was resistant to all medical treatments and was treated surgically, first for the axilla then the inguinal area.

Inguinal area reconstruction was achieved using bilateral pedicled ALT flaps, and the challenge was the reconstruction of the scrotum, which was severely affected and enlarged because of HS-associated lymphedema. Scrotal lymphedema is a challenging and debilitating sequela of chronic, long-standing HS13.

Local flaps were not an option because of the involvement of the surrounding tissues, so we decided to go for split thickness skin grafting. The next challenge was how to secure the graft in such big circumferential areas (scrotum). Our goal was to provide good adhesion to the bed, maintaining a wet environment that promotes healing and to drain the excess fluid and blood, so we created our own technique using a piece of sterile glove that is simple and available in any hospital setting.

The first dressing was done on the sixth day postoperation, which showed complete graft intake, then every other day till complete graft healing at 14 days postoperation.

This paper is the first to describe such a technique to cover a big, spherical raw area in the scrotum, which has the potential help to decrease the rate of graft loss, promote healing and avoid exposing the patient to further procedures. We recommend testing this technique when grafting the scrotum or any circumferential area to secure the graft where there is a high probability of graft mobility and fear of loss.

Conclusion

HS can be a debilitating disease, in its severe forms surgical intervention is needed. Surgical options of reconstructions vary, grafting is one of the options. Here, we deliver a new technique to secure the graft on the scrotum which showed promising results.

Patient consent

Informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Consent to participate and consent for publication

All authors were actively involved in the review, and all approved the final manuscript for publication.

Provenance and peer review

Not commissioned, externally peer-reviewed

Ethical approval

No ethical approval was needed.

Sources of funding

Supported by the Qatar National Library for funding the open access publication of this paper.

Author contribution

S.A.L.: conceptualization, supervision (lead); writing—review and editing. G.A.: original draft preparation, writing, literature review, editing. H.A.-B.: supervision, review and editing. Z.T.N.A.: writing and editing. R.S.: review and editing.

Conflicts of interest disclosure

The authors declare that they have no financial conflict of interest with regard to the content of this report.

Research registration unique identifying number (UIN)

The paper was submitted to ResearchRegistry with a ResearchRegistry unique identifying number (UIN): researchregistry 6081.

Guarantor

Salim Al Lahham.

Acknowledgments

The authors acknowledge the Qatar National Library for funding the open access publication of this review. They acknowledge the peer reviewers for their valuable comments and feedback that led to significantly improve the manuscript.

References

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2. Ingram JR, Jenkins-Jones S, Knipe DW, et al. Population-based Clinical Practice Research Datalink study using algorithm modelling to identify the true burden of hidradenitis suppurativa. Br J Dermatol 2018;178:917–24.
3. Alikhan A, Lynch PJ, Eisen DB. Hidradenitis suppurativa: a comprehensive review. J Am Acad Dermatol 2009;60:539–63.
4. Canoui-Poitrine F, Le Thuaut A, Revuz JE, et al. Identification of three hidradenitis suppurativa phenotypes: latent class analysis of a cross-sectional study. J Invest Dermatol 2013;133:1506–111.
5. Agha RA, Borrelli MR, Farwana R, et al. For the SCARE Group. The SCARE 2018 Statement: Updating Consensus Surgical Case Report (SCARE) Guidelines. Int J Surg 2018;60:132–6.
6. Al Lahham S, Aljassem G, Al-Basti H, et al. Grafting a spherical hidradenitis-affected scrotal raw area using a sterile glove—a case report describing Al Lahham Technique. Research Registry. Available at: https://www.researchregistry.com/browse-the-registry#home/. Accessed October 4, 2020.
7. Hurley HJ Roenigk RK, Roenigk HH. Axillary hyperhidrosis, apocrine bromhidrosis, hidradenitis suppurativa, and familial benign pemphigus: surgical approach. Dermatologic Surgery. New York, NY: Dekker; 1989:729.
8. Ritz JP, Runkel N, Haier J, et al. Extent of surgery and recurrence rate of hidradenitis suppurativa. Int J Colorectal Dis 1998;13:164–8.
9. Ellis LZ. Hidradenitis suppurativa: surgical and other management techniques. Dermatol Surg 2012;38:517–36.
10. Harrison BJ, Mudge M, Hughes LE. Recurrence after surgical treatment of hidradenitis suppurativa. Br Med J 1987;294:487–9.
11. Mandal A, Watson J. Experience with different treatment modules in hidradenitis suppuritiva: a study of 106 cases. Surgeon 2005;3:23–6.
12. Watson JD. Hidradenitis suppurativa—a clinical review. Br J Plast Surg 1985;38:567–9.
13. Micieli R, Alavi A. Lymphedema in patients with hidradenitis suppurativa: a systematic review of published literature. Int J Dermatol 2018;57:1471–80.
Keywords:

Hidradenitis suppurativa; Surgical; Treatment; Graft

Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of IJS Publishing Group Ltd.