Carbon dioxide laser treatment for hidradenitis suppurativa

BOSTON ― The use of carbon dioxide (CO2) laser excision therapy for hidradenitis suppurativa (HS) is not associated with an increased risk for the development of keloids, new research shows.

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Does laser help hidradenitis suppurativa?
Does insurance cover laser hair removal for hidradenitis suppurativa?
What is the best way to get rid of hidradenitis suppurativa?
Does laser hair removal help hidradenitis?

"With keloids disproportionately affecting Black and other skin of color patients, denying treatment on a notion that lacks evidentiary support further potentiates the health disparities experienced by these marginalized groups," the researchers reported at the Annual Meeting of the Skin of Color Society Scientific Symposium (SOCS) 2022. In their retrospective study of 129 patients with HS treated with CO2 laser, "there were no cases of keloid formation," they say.

HS, a potentially debilitating chronic inflammatory condition that involves painful nodules, boils, and abscesses, is often refractory to standard treatment. CO2 laser excision therapy has yielded favorable outcomes in some studies.

Although CO2 laser therapy is also used to treat keloids, some clinicians hesitate to use this treatment in these patients because of concerns that its use for treating HS could trigger the development of keloids.

"Many patients come in telling us they were denied [CO2 laser] surgery due to keloids," senior author Iltefat Hamzavi, MD, a senior staff physician in the Department of Dermatology at the Henry Ford Health System, in Detroit, Michigan, told Medscape Medical News.

Although patients with HS are commonly treated with CO2 laser excision in his department, this treatment approach "is underused nationally," he said.

"Of note, the sinus tunnels of hidradenitis suppurativa can look like keloids, so this might drive surgeons away from treating [those] lesions," Hamzavi said.

To further evaluate the risk of developing keloids with the treatment, Hamzavi and his colleagues conducted a retrospective review of 129 patients with HS treated at Henry Ford who had undergone follicular destruction with CO2 laser between 2014 and 2021; 102 (79%) patients were female. The mean age was about 38 years (range, 15 to 78 years).

Of the patients, almost half were Black, almost 40% were White, 5% were Asian, and 3% were of unknown ethnicity.

Medical records of nine patients included diagnoses of keloids or hypertrophic scars. Further review indicated that none of the diagnoses were for keloids but were for hypertrophic scars, hypertrophic granulation tissue, an HS nodule, or contracture scar, the authors report.

"While the emergence of hypertrophic scars, hypertrophic granulation tissue, and scar contracture following CO2 laser excision therapy for hidradenitis suppurativa has been documented in the literature, existing evidence does not support post-operative keloid formation," the authors conclude.

Because healing time with CO2 laser treatment is prolonged and there is an increase in risk of adverse events, Hamzavi underscored that "safety protocols for CO2 lasers should be followed, and wound prep instructions should be provided along with counseling on healing times."

Regarding patient selection, he noted that "the disease should be medically stable with reduction in drainage to help control postop bleeding risk."

The findings of the study are supported by a recent systematic review that compared outcomes and adverse effects of treatment with ablative laser therapies with nonablative lasers for skin resurfacing. The review included 34 studies and involved 1093 patients. The conditions that were treated ranged from photodamage and acne scars to HS and posttraumatic scarring from basal cell carcinoma excision.

That review found that overall, rates of adverse events were higher with nonablative therapies (12.2%, 31 events) in comparison with ablative laser therapy, such as with CO2 laser (8.28%, 81 events). In addition, when transient events were excluded, ablative lasers were associated with fewer complications overall in comparison with nonablative lasers (2.56% vs 7.48%).

The authors conclude, "It is our hope that this study will facilitate continued research in this domain in an effort to combat these inequities and improve access to CO2 excision or standardized excisional therapy for hidradenitis suppurativa treatment."

Hamzavi and the other authors have disclosed no relevant financial relationships.

Annual Meeting of the Skin of Color Society Scientific Symposium (SOCS) 2022: Poster 49. Presented March 24, 2022.

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As many patients know, much hidradenitis surgery, including CO2 laser excision and marsupialization, is not reimbursed at an appropriate rate by insurance companies. The poor reimbursement has led many physicians to avoid caring for patients with HS, and prompted the HS Institute to become a fee-for-service provider wherein no insurance plans are accepted. We continue to work with most insurance plans in our efforts to facilitate insurance coverage, primarily through a reimbursement system for services provided.

Factors which determine the complexity of a treatment session determine the cost of surgery. These factors include time of the procedure, materials used during the surgery, patient comfort issues and medications needed for pain control, and safety of anesthetic agents used. Large areas, requiring greater quantities of local anesthesia, demand careful determinations of total dose of such medications. Treatment of a single region can therefore require several sessions for completion. Additional sessions are typically at lesser costs.

Utilizing the CO2 laser surgery for treatment of HS is still a relatively new treatment modality and as such, is not properly reimbursed by insurance plans. The HS Institute would like to enlist the help of all patients and their networks to “get the word out” by contacting their insurance company to discuss HS and this form of treatment. We believe that as insurance companies learn more about the effectiveness of the surgery, they will adjust their reimbursement appropriately.

Notable benefits to the CO2 laser surgery for HS include:

The treatment appears to be much more successful than other treatments, thereby reducing the need for repeat surgeries, and improving the overall costs of care.
The treatment can usually be done in the office, using local anesthesia, thereby avoiding the cost of operating rooms, and the risks of general anesthesia.
The treatment does not require post-operative hospital recovery. This further reduces the cost of the surgery, and allows patients to resume their normal life activities more quickly.

A letter template is available through the HS Institute by e-mailing:

Does laser help hidradenitis suppurativa?

How effective is it? In studies, laser hair removal improved HS by 32 to 72 percent after 2 to 4 months of treatment. However, the treatment only seems to work in people with mild disease — those with stage 1 or 2 HS. One advantage to laser treatment is that it doesn't cause body-wide side effects like pills do.

Does insurance cover laser hair removal for hidradenitis suppurativa?

Laser hair removal treatment can be a good option for HS, especially if other treatments have failed to work. However, if you're considering laser hair removal to help treat HS, it's important to consider the cost as it's not always covered by insurance and results may not be permanent.

What is the best way to get rid of hidradenitis suppurativa?

Mild symptoms might be managed with a topical antibiotic in liquid or gel form. For more-widespread disease, your doctor might prescribe antibiotic pills, such as doxycycline (Monodox), clindamycin (Cleocin), rifampin (Rimactane) or both. People with severe disease might need to take antibiotics for months.