化脓性汗腺炎术前超声检查指南

Redina Bardhi, Mohsen Mokhtari, Mavra Masood, Jasira Ziglar, Sydney Colbert, Iltefat Hamzavi, Indermeet Kohli
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As such, pre-surgical margin mapping with HFU, before carbon dioxide (CO<sub>2</sub>) laser surgery—an effective treatment for HS, may reduce recurrence rates. However, there is minimal existing literature regarding the margin mapping methodology. This letter provides a practical framework for ultrasound mapping of HS lesions before CO<sub>2</sub> laser excision.</p><p>It is important to become familiar with ultrasound features of skin layers to delineate HS lesions from healthy tissue. In healthy skin, the epidermis is the outermost layer, appearing as a hyperechoic line [<span>3</span>]. Beneath, lies the dermis, a thick and heterogeneous layer with hyperechoic reflections of collagen fibres [<span>3</span>]. Lastly, the hypodermis sits below the dermis, appearing as a hypoechoic fat interdispersed with linear hyperechoic reflections representing connective tissue [<span>3</span>]. 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引用次数: 0

摘要

化脓性汗腺炎(HS)是一种慢性炎症性皮肤病,以脓肿、结节和窦道为特征。虽然HS的诊断和分期标准是基于临床表现,但这可能低估了疾病的严重程度和程度。高频超声(HFU)已被证明是高度敏感的,当结合临床检查划定HS病变的范围b[1]。它提供了病变形态和严重程度的重要细节,有助于跟踪疾病进展和指导治疗方案。因此,作为HS b[2]的有效生物标志物,它获得了高评级。因此,在二氧化碳(CO2)激光手术(一种治疗HS的有效方法)之前,术前用HFU进行边缘定位可能会降低复发率。然而,关于边界制图方法的现有文献很少。这封信提供了一个实用的框架超声测绘HS病变前CO2激光切除。熟悉皮肤层的超声特征对于从健康组织中区分HS病变是很重要的。在健康皮肤中,表皮是最外层,呈高回声线[3]。下面是真皮层,这是一层厚而不均匀的胶原纤维[3]的高回声反射层。最后,真皮位于真皮下方,表现为低回声脂肪,呈线性高回声反射,代表结缔组织[3]。HS的超声特征包括真皮增厚,真皮回声较低提示水肿、无回声或低回声液体沉积,以及毛囊变宽[3,4]。此外,真皮层或皮下的瘘道表现为低回声或低回声带状结构,而假性囊肿表现为椭圆形低回声或低回声结节状结构[4]。关于CO2激光切除前边缘定位的HFU成像,建议采用以下方法。在触诊特定病变估计范围后,超声探头应垂直于病变位置。在此过程中,应施加最小的压力,用小指保持手的稳定和抬高,同时通过凝胶床与皮肤接触(图1)。建议使用1 - 2厘米的凝胶床,以便更好地观察表面特征[5]的变化。较低频率的探头,如12mhz,最初可用于发现更深的病变,因为这些探头可以提供更深入的成像,尽管分辨率相对较低[5,6]。更高频率的探头,范围从15到22 MHz,可以用于更详细地可视化感兴趣的区域[5,6]。在HS的特征性HFU特征中,真皮增厚的变化被认为是术前边缘作图时最相关的特征(图1)。因此,对于边缘作图而言,一旦定位到窦道或液体沉积物,操作者必须跟随其到达其终点,即正常真皮与增厚真皮之间的过渡点。应在病变周围每隔1 - 2厘米进行一次皮肤标记,以划定切除区域(图2)。应评估周围皮肤2 - 3厘米内的孤立病变是否存在与主要病变相连的窦道,因为窦道会影响待切除区域。此外,多普勒特征可用于避开高血流量区域。切除所有病变组织以达到治愈和减少复发是非常重要的。采用上述方法的HFU成像可以通过消除临床检查中操作人员之间的差异来帮助实现这一目标。我们分析了三名患者的数据,他们在CO2手术前接受了HFU成像,没有复发,证明了HFU和我们的技术在CO2激光手术前的术前测绘的有效性。人口学资料、病变部位、大小及术后无复发天数如下:第一位患者为男性,46岁,手术部位为左腋窝(96 cm²),术后154天伤口愈合,无复发。第二例患者是一名46岁的女性,她在右腋窝(130 cm²)上进行了手术,147天完成闭合,无复发。第三例患者为24岁女性,右腋窝(63 cm²)手术,术后112天闭合,无复发。考虑到这些有希望的初步发现,未来的大规模研究有必要评估CO2激光切除前HS病变的HFU制图与复发率之间的相关性。Indermeet Kohli和Iltefat Hamzavi博士创建了方法并编辑了手稿,Redina Bardhi博士、Mohsen Mokhtari博士和Mavra Masood博士进行了实验并起草了手稿,Ziglar博士和Sydney Colbert博士收集了数据。 本文中的所有患者均已书面知情同意参与研究,并同意使用其去识别数据和病例详细信息(包括照片)进行发表。机构审查委员会:7851-18。Iltefat Hamzavi:拜耳、UCB、HS Foundation、Boerhinger Ingelhei、Sonoma、Union therapeutics、诺华、Jansen、Almirall、默克、Clinuvel、艾伯维、辉瑞、Incyte、Jansen、Avita、默克、Vimela、ITN、高德美、Sonoma、Union therapeutics、MyDermPortal、Chemocentyx、全球白癜风基金会、Arcutis、Unigen、Loreal/Laroche Posay、芬代尔实验室、雅诗兰黛。其他作者声明没有利益冲突。
本文章由计算机程序翻译,如有差异,请以英文原文为准。

Pre-Operative Ultrasonography Guide for Hidradenitis Suppurativa

Pre-Operative Ultrasonography Guide for Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition characterised by abscesses, nodules, and sinus tracts [1]. Although diagnostic and staging criteria for HS are based on clinical findings, this may underestimate the severity and extent of disease [1]. High frequency ultrasound (HFU) has been shown to be highly sensitive when combined with clinical examination in delineating the extent of HS lesions [1]. It provides important details on lesion morphology and severity, aiding in tracking disease progression and guiding treatment options. Thus, it has received a high-grade rating as a valid biomarker for HS [2]. As such, pre-surgical margin mapping with HFU, before carbon dioxide (CO2) laser surgery—an effective treatment for HS, may reduce recurrence rates. However, there is minimal existing literature regarding the margin mapping methodology. This letter provides a practical framework for ultrasound mapping of HS lesions before CO2 laser excision.

It is important to become familiar with ultrasound features of skin layers to delineate HS lesions from healthy tissue. In healthy skin, the epidermis is the outermost layer, appearing as a hyperechoic line [3]. Beneath, lies the dermis, a thick and heterogeneous layer with hyperechoic reflections of collagen fibres [3]. Lastly, the hypodermis sits below the dermis, appearing as a hypoechoic fat interdispersed with linear hyperechoic reflections representing connective tissue [3]. Features of HS on ultrasound include increased dermal thickening, lower echogenicity of the dermis suggesting edema, anechoic or hypoechoic fluid deposits, and widening of hair follicles [3, 4]. Additionally, fistulous tracts appear as anechoic or hypoechoic band-like structures in the dermis or hypodermis, while pseudocysts appear as oval-shaped hypoechoic or anechoic nodular structures [4].

Regarding HFU imaging specific to margin mapping before CO2 laser excision, the following methodology is recommended. After palpating the specific lesions to estimate extent, the US probe should be positioned perpendicular to the lesion. This should be done while applying minimal pressure and using the little finger to keep the hand steady and elevated, while in contact with the skin through a gel bed (Figure 1). A 1−2 cm gel bed is recommended for better visualisation of changes in superficial features [5]. A lower frequency probe, such as 12 MHz, may be used initially to find deeper lesions, as these probes provide greater depth of imaging, although at a relatively lower resolution [5, 6]. A higher frequency probe, with range from 15 to 22 MHz, may be utilised next to visualise areas of interest in greater detail [5, 6]. Among the characteristic HFU features of HS, change in dermal thickening was identified as the most pertinent feature when performing preoperative margin mapping (Figure 1). As such, specific to margin mapping, once a sinus tract or fluid deposit has been located, the operator must follow it to where it ends, which corresponds to the transition point between normal and thickened dermis. This should be marked with a skin marker and performed every 1−2 cm around the lesion to demarcate the area of excision (Figure 2). Isolated lesions within 2−3 cm on the surrounding skin should be evaluated for the presence of any sinus tracts connecting them to the main lesion, as that would impact the area to be excised. Furthermore, the Doppler feature may be utilised to avoid areas with high blood flow.

It is highly important to excise all diseased tissue to achieve cure and reduce recurrence. HFU imaging, employing the methodology described above, can help achieve this by eliminating inter-operator variability in clinical examinations [2]. We analysed data from three patients who underwent HFU imaging before the CO2 surgery and had no recurrence demonstrating the effectiveness of HFU and our technique for pre-surgical mapping before CO2 laser surgery. The demographic details, lesion site and size and days post-surgery when no recurrence was observed are as follow: The first patient was a 46-year-old male who had surgery on the left axilla (96 cm²), with wound closure at 154 days and no recurrence. The second patient was a 46-year-old female who underwent surgery on the right axilla (130 cm²), achieving closure at 147 days with no recurrence. The third patient, a 24-year-old female, had surgery on the right axilla (63 cm²), with closure at 112 days and no recurrence. Considering these promising preliminary findings, future large-scale studies are warranted to evaluate the correlation between HFU mapping of HS lesions before CO2 laser excision and recurrence rates.

Dr. Indermeet Kohli and Dr. Iltefat Hamzavi created the methodology and edited the manuscript, Dr. Redina Bardhi, Mohsen Mokhtari, and Dr. Mavra Masood performed the experiments and drafted the manuscript, and Dr. Ziglar and Sydney Colbert collected data.

All patients in this manuscript have given written informed consent for participation in the study and the use of their de-identified data and their case details (including photographs) for publication. Institutional Review Board: 7851-18.

Iltefat Hamzavi: Bayer, UCB, HS Foundation, Boerhinger Ingelhei, Sonoma, Union therapeutics, Novartis, Jansen, Almirall, Merck, Clinuvel, Abbvie, Pfizer, Incyte, Jansen, Avita, Merck, Vimela, ITN, Galderma, Sonoma, Union therapeutics, MyDermPortal, Chemocentyx, Global Vitiligo Foundation, Arcutis, Unigen, Loreal/Laroche Posay, Ferndale Laboratories, Estee Lauder. The other authors declare no conflicts of interest.

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