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Hello
I have a patient that has a severe case of Hidradenitis suppurativa along with Psoriasis. In 4/2021 he had a case of Fournier's gangrene that was surgically treated and closed with a wound vac and dressings. He has a history of abscess that come and go. There is one area left that is not healing and is strictly a tunnel measuring 0.3 cm x 0.3 cm x 10.5 depth to his right posterior thigh. He is morbidly obese with diabetes. He recent treatment has been Doxycycline, Minocycline, Augmentin, Levaquin. He also was on acitretin at an increased dose that showed the best improving (depth 4cm) but he had an allergic reaction and had to stop the medication. At the end of March, he had cellulitis of the right medial thigh where he has lymphedema that was treated with IV antibiotics and Augmentin on discharge. CT pelvis did not show gangrene but extensive cellulitis and he was seen by general surgeon.
I have tried many dressings and pure and clean washes. Dressings have included, hydrofera blue, silver rope, prisma, microlyte, plain gauze packing. At this time, it is so small in diameter but deep that I am not sure what else to use for dressings in fear of loosing it to the depth.
He has been seeing a dermatologist as well that recently tried to get him on Humira but due to risk for CHF they choose to forgo. Now they are looking at trying Methotrexate.
Any pearls of wisdom for dressings and management.

Thank you! Shelly Hardman , APRN
Apr 20, 2022 by Shelly Hardman, APRN
2 replies
David Charash
DO,CWS,FACEP,FUHM
GOOD EVENING!. Hidradenits Suppurativa (HS) can be very challenging. Of course this patient has a number of additional co morbidities that make this exceptionally challenging. In general Severe HS is a multidisciplinary team approach. Chronic suppressive antibiotics can be helpful in decreasing secondary infections. In general I would want to focus on decreasing colonization vs supracolinzation vs infection. As Dakins can inhibit wound healing, it is also effective in decreasing colonization. r I have had success using Vashe, however it is a very expensive product, often not covered by insurance. Regarding dressing selection, I have found the use of hydrofibers very useful. Because of its capacity to have tensile strength, it can be used in areas of tunneling in the ribbon form. Having a rather long tail exterior to wound and securing this dressing, will make removal much easier. You might need to discuss with surgeon if it is advisable to open the small opening to allow better address of wound. Thank you for sharing g with us this very challenging case.
Apr 20, 2022
Thank you so much for your response. Since my post the wound is improving on Methotrexate. I will look into using a Hydrofiber if the tunnels increase again, crossing my fingers they continue to heal.
May 12, 2022
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