In small areas, in obese patients with redundant skin, you can close the wound primarily. The wound can be excised and left open with a VAC, which is a negative pressure sponge. They can be treated open with hydrocolloid dressings. They can be treated open with or without a VAC and some wound care, then skin grafted in primary or delayed settings. Intraoperatively, marking is done with topical iodine and starch and oxytocin is administered to identify all the areas in which there is apocrine-bearing skin, so the excision can be more complete. Another important component post-excision is physical therapy. A lot of these problems are painful and disabling and patients won't lift their arms up over their heads. So to maintain range of motion of their joints, they need physical therapy.
I think you just have to accept that recurrences are going to happen. It seems to be site-specific. Axillary disease is the most common, but the area where we are most successful. These patients can be managed with excision and skin graft with a very low recurrence rate, around 3%. But perineal and perianal disease is very difficult - 37% recurrence rate - and surprisingly intra and inframammary disease is very difficult to eradicate with at least a 50% recurrence rate.
So going back to our recommendations:
- lifestyle changes with counseling about weight reduction and proper diet
- the 3 Hs - health, hygiene and Hibiclens - using a 5% chlorhexidine solution 2-3 times/week to reduce bacterial counts
- topical clindamycin and benzoyl peroxide are the next arm of therapy similar to acne
- systemic antibiotics include tetracycline, Bactrim and clindamycin
- limited excision with primary closure is restricted to those with quiescent axillary disease