Minimally invasive management of Hidradenitis suppurativa using a 1470nm diode laser. A step-by-step description of our technique.

Minimally invasive management of Hidradenitis suppurativa using a 1470nm diode laser. A step-by-step description of our technique. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Minimally invasive management of Hidradenitis suppurativa using a 1470nm diode laser. A step-by-step description of our technique. Nana Kwame D. Brown, Philemon K. Kumassah, George D. Brown, Solomon Brookman, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4972660/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Jan, 2025 Read the published version in BMC Surgery → Version 1 posted 4 You are reading this latest preprint version Abstract Background The management of hidradenitis suppurativa (HS) requires a multidisciplinary approach to ensure sustainable treatment results, especially in the advanced stages. Traditionally, deroofing and wide excision represented commonly employed surgical techniques. Due to the recurrent nature of HS, tissue preservation should be a relevant aspect of the surgical management. The aim of this manuscript is to demonstrate the use of a diode laser for the management of different stages of HS, paying attention on tissue preservation. Methods This is a technical manuscript demonstrating our technique for laser–assisted management of HS. A diode laser with a wavelength of 1470nm was used for this indication. The depth of the sinus/tract dictates the amount of energy required. Our preference is to use 8 Watts for deep lesions and 5 Watts for shallow lesions. Results: The following 7 critical steps are important to achieve an optimal result with this technique: Drain all collections, minimalize tissue damage, protect healthy skin, control risk factors, adopt a multidisciplinary approach, follow-up closely, and be patient. Conclusion: Laser-based management of hidradenitis suppurativa is a promising surgical option in the multidisciplinary treatment of this difficult pathology. The minimally invasive nature of laser surgery, especially tissue preservation, is a strong argument for the role of this technique in the management of this chronic, recurrent condition. Hidradenitis suppurativa Hidradenitis Acne inversa laser therapy diode laser dermatology laser surgery Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Hidradenitis suppurativa (HS) is a chronic, recurrent, inflammatory condition involving the apocrine glands around the axilla (armpit), breast, groin, perineum and perianal regions 1 . The condition most commonly affects young individuals from adolescence to early 40s 2 . The disorder is thought to have a multi-factorial genesis with both genetic and epigenetic predispositions. The genetic aspect is backed by its occurrence in specific families with the involvement of many generations, thus supporting a possible autosomal dominant inheritance pattern 3 . Epigenetic aspects of HS constitute well-recognized association with the use of nicotine, obesity and diabetes. Some authors see HS as an autoimmune disorder, like inflammatory bowel disease 4 , 5 . The clinical spectrum of presentation is characterized by a chronic, recurrent and eventually progressive behavior, which is best described using the Hurley classification 6 . According to this classification, and its different modifications, grade I disease is characterized by inflammatory, isolated nodules. Left untreated, these nodules may develop into fistulae, some of which get connected (Hurley grade II) 7 . In an attempt to control the recurrent inflammation, scars eventually develop leading to a disfiguring picture (Hurley grade III) 8 . The diagnosis of HS is easily made per visualization 9 . The three primary clinical features that support a diagnosis of Hidradenitis Suppurativa (HS) are: Typical lesions: These include multiple deep-seated inflamed nodules, tombstone comedones, skin tunnels, abscesses, and/or fibrotic scars. Typical locations: The lesions commonly occur in the axillae, groin, and inframammary areas, often presenting with a bilateral distribution. Relapses and chronicity: The condition is characterized by recurring episodes and chronicity 10 . Although histopathology is not routinely needed, it should be considered in selected cases to rule out malignancy, e.g. squamous cell cancer 11 . Inspection of all predilection sites should be done in all patients suspected of or presenting with HS 12 . The management of HS should be multidisciplinary including both conservative or medical strategies and surgery 13 , 14 . Many international guidelines suggest a stepwise, grade-guided treatment algorithm including topical and systematic antibiotics, hormone-directed strategies, immune modulation and surgery 14 . The surgical strategy may range from a limited procedure like deroofing to extensive procedures like wide excision and fecal deviation with or without plastic reconstruction 15 . The laser techniques constitute an item within the surgical armamentarium 16 . The aim of this manuscript is to describe our technique of minimally invasive management of HS using a diode laser and to discuss this technique with respect to available literature. Methods This is a technical manuscript demonstrating our technique for laser–assisted management of HS. We use a diode laser (Biolitec, Germany) with a wavelength of 1470nm for this indication. The depth of the sinus/tract dictates the amount of energy required. Our preference is to use 8 Watts for deep lesions and 5 Watts for shallow lesions. The laser energy is emitted at the tip of the probe in a circular fashion leading to denaturation of the proteins along the inflammatory tracts. This combined with gentle compression causes the tract to collapse and close. The laser penetrates the skin to selectively target and thermally destroy the follicular unit and organized inflammatory lesions within the superficial to mid-dermis 17 . The procedure can be performed with general or local anesthesia as needed. The pathologic lesion is punctured and gently curetted. Attention must be paid to the size of the debriding instrument to prevent dilating the tract. Irrigation can be done in selected cases. Results The following seven points should be considered when managing these patients: 1. Draining all collections : This is best achieved via a small incision at the apex of the collection prior to laser application. In cases with large collections and purulent secretion, laser surgery should be omitted. A gentle debridement of the tract may be performed. Irrigation is optional (Figures 1a & 1b). 2. Minimalize Tissue Damage: This is achieved by making small incisions for drainage and by regulating the amount of laser energy applied to the tissue. 3. Protect Healthy Skin: Superficial tracts within the subcutis may be covered just by a thin skin layer. This healthy skin should be protected from thermal damage via reducing the amount of laser energy applied and by applying a wet/cold gauze on the area during treatment (Figure 2a). 4. Control Risk Factors: Smoking is a relevant risk factor for HS and quitting smoking may significantly influence the course of HS and treatment success. 5. Multidisciplinary Approach: This includes but is not limited to the use of prolonged antibiotics, antihormonal therapy and biologics. 6. Close Follow-Up: The chronic and recurrent nature of HS requires a close follow-up. (Figure 2b: Day 7 Post-Op) 7. Patience: Healing post-op may take some time. The surgery can be performed both under general or local anesthesia; even as an outpatient procedure. Postoperative wound dressing is done with a simple gauze. Postoperative pain is minimal and return to work is possible on Post-Op Day 1. Extensive disease usually requires more than one treatment session and additional treatment such as the use of biologics (Figures 3 - 4). Discussion Over many decades the surgical management of HS has included procedures from limited local procedures like incision and drainage and deroofing to more extensive resections, with additional procedures like creating a stoma for fecal deviation. Some of these procedures led to excellent control at high costs for the patients with regards to risk of morbidity and quality of life. Thus, the need for less invasive surgical options with similar disease control became apparent. This manuscript presents our technique of performing laser surgery for patients with HS. This technique uses a well-defined amount of laser energy to destroy the epithelial lining of sinuses and tracts seen in patients with HS. This results in denaturization of proteins in the sinuses and tracts, which subsequently collapse and close secondary to the adhesive effect of the denaturized proteins. The use of laser in the management of HS is a well-recognized approach that has been stated in numerous treatment recommendations and guidelines. In the 2016 European guidelines for HS, Laser treatment was recommended for Hurley II and III 18 . Laser treatment in these guidelines reached a strong recommendation due to the high evidence level from the randomized controlled trial by Tierney et al using the Nd:YAG laser 16 . In recent years, more appealing data has been reported for the use of laser technology in HS. While some of this data is related to the effect of hair removal in patients with HS, there is nonetheless increasing experience with the use of this modality to manage this rather challenging pathology 19 – 21 . Our experience with laser-associated treatment of patients with HS is similar to findings from the current literature. However, the multifaceted nature of Hydradenitis warrants a multidisciplinary approach. Therefore, we routinely use a combination of treatment options in the management of our patients. Our standard algorithm is to combine laser with a long course of antibiotics in patients with Hurley stages I and II and to escalate to a biologic in patients who are unresponsive to and do not tolerate antibiotics 14 . Also, we recommend biologics in patients with extensive disease and those with Hurley stage III 14 . We have observed so far that almost all our patients with stage I would need just a single laser intervention for good control. Patients with stages II and III may require repeated intervention. In such cases, we recommend repeated surgeries at 6–8 week intervals. While most data in the literature report on the use of either the CO 2 or the Nd:YAG laser, our experience is based on the diode laser. Thus, a direct comparison may be questionable. Irrespective of the above limitation, the minimally invasive laser surgery for HS largely preserves the tissue. Laser surgery has been shown to significantly reduce postoperative pain and morbidity, leading to an early return to work and a better quality of life. It would be interesting to study the positive experiences reported in this manuscript in a prospective setting with more patients. Conclusion Laser-based management of hidradenitis suppurativa is a promising surgical option in the multidisciplinary treatment of this difficult pathology. The minimally invasive nature of laser surgery, especially tissue preservation, is a strong argument for the role of this technique in the management of this chronic, recurrent condition. Abbreviations HS Hidradenitis suppurativa Declarations Acknowledgement : Many thanks to Biolitec for material support. Competing Interests : The authors declare that they have no competing interests. Ethics approval: Was not necessary blinded images without patient´s data were used Consent for publication : All patients consented on the use of anonymized images. Clinical Trial Number : Not applicable Authors´contributions: PCA conceptualized the manuscript. NKDB, PCA, KA and PKK designed the manuscript. GDB, SB, PKK, PCA and KA performed literature research for the manuscript. NKDB drafted the manuscript. PKK and KA edited the manuscript. All authors read and approved the final draft. References Luporini RL, Frizol SM, Segantini MJ, Pereira LD, Fontanella AP, Féres O. Hidradenitis suppurativa perineal and perianal. Benign Anorectal Disorders-An Update. IntechOpen; 2022. Choi E, Ooi XT, Chandran NS. Hidradenitis suppurativa in pediatric patients. J Am Acad Dermatol. 2022;86(1):140–7. Jfri A. Hidradenitis Suppurativa: The Study of Natural History, Genetics, Comorbidities and Impact on Patient’s Life. McGill University (Canada); 2020. Constantinou CA, Fragoulis GE, Nikiphorou E. Hidradenitis suppurativa: infection, autoimmunity, or both? Ther Adv Musculoskelet Dis. 2019;11:1759720X19895488. Zouboulis CC, Benhadou F, Byrd AS, et al. What causes hidradenitis suppurativa?—15 years after. Exp Dermatol. 2020;29(12):1154–70. Revuz J. Hidradenitis suppurativa. J Eur Acad Dermatol Venereol. 2009;23(9):985–98. Vinkel C, Thomsen SF. Hidradenitis suppurativa: causes, features, and current treatments. J Clin Aesthet Dermatol. 2018;11(10):17. Margesson LJ, Danby FW. Hidradenitis suppurativa. Best Pract Res Clin Obstet Gynaecol. 2014;28(7):1013–27. Wortsman X. Diagnosis and treatment of hidradenitis suppurativa. JAMA. 2018;319(15):1617–8. John H, Manoloudakis N, Sinclair JS. A systematic review of the use of lasers for the treatment of hidradenitis suppurativa. J Plast Reconstr Aesthetic Surg. 2016;69(10):1374–81. Lapins J, Ye W, Nyrén O, Emtestam L. Incidence of cancer among patients with hidradenitis suppurativa. Arch Dermatol. 2001;137(6):730–4. Collier EK, Parvataneni RK, Lowes MA, et al. Diagnosis and management of hidradenitis suppurativa in women. Am J Obstet Gynecol. 2021;224(1):54–61. Shukla R, Karagaiah P, Patil A, et al. Surgical treatment in hidradenitis suppurativa. J Clin Med. 2022;11(9):2311. Hendricks AJ, Hsiao JL, Lowes MA, Shi VY. A comparison of international management guidelines for hidradenitis suppurativa. Dermatology. 2021;237(1):81–96. Ovadja ZN, Bartelink SAW, Hadi K, Van De Kar AL, Van Der Horst CMAM, Lapid O. A multicenter analysis of wide excision and reconstruction for severe anogenital hidradenitis suppurativa. Ann Plast Surg. 2021;86(2):193–200. Tierney E, Mahmoud BH, Hexsel C, Ozog D, Hamzavi I. Randomized control trial for the treatment of hidradenitis suppurativa with a neodymium-doped yttrium aluminium garnet laser. Dermatol Surg. 2009;35(8):1188–98. Xu LY, Wright DR, Mahmoud BH, Ozog DM, Mehregan DA, Hamzavi IH. Histopathologic study of hidradenitis suppurativa following long-pulsed 1064-nm Nd: YAG laser treatment. Arch Dermatol. 2011;147(1):21–8. Gulliver W, Zouboulis CC, Prens E, Jemec GBE, Tzellos T. Evidence-based approach to the treatment of hidradenitis suppurativa/acne inversa, based on the European guidelines for hidradenitis suppurativa. Rev Endocr Metab Disord. 2016;17(3):343–51. Lindsø Andersen P, Riis PT, Thorlacius L, et al. Intense pulsed light treatment for hidradenitis suppurativa: a within-person randomized controlled trial. Eur J Dermatology. 2020;30:723–9. Cazaña TG, Díaz LVB, Sánchez JIM, Nasarre IQ, Gilaberte Y. Systematic review of light-based treatments for hidradenitis suppurativa. Actas Dermo-Sifiliográficas (English Edition). 2020;111(2):89–106. van Rappard DC, Mekkes JR, Tzellos T. Randomized controlled trials for the treatment of hidradenitis suppurativa. Dermatol Clin. 2016;34(1):69–80. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 23 Jan, 2025 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 29 Aug, 2024 Editor assigned by journal 28 Aug, 2024 Submission checks completed at journal 28 Aug, 2024 First submitted to journal 25 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4972660","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":346821809,"identity":"b679f715-a56d-4866-8427-fb541d0598f3","order_by":0,"name":"Nana Kwame D. Brown","email":"","orcid":"","institution":"Korle Bu Teaching Hospital Accra, Ghana","correspondingAuthor":false,"prefix":"","firstName":"Nana","middleName":"Kwame D.","lastName":"Brown","suffix":""},{"id":346821815,"identity":"1b27279a-4c1e-40ee-bfc9-0e428abcd03a","order_by":1,"name":"Philemon K. Kumassah","email":"","orcid":"","institution":"Korle Bu Teaching Hospital Accra, Ghana","correspondingAuthor":false,"prefix":"","firstName":"Philemon","middleName":"K.","lastName":"Kumassah","suffix":""},{"id":346821819,"identity":"4ae29a6b-fa2a-466b-ad51-b6915c1758c0","order_by":2,"name":"George D. Brown","email":"","orcid":"","institution":"Korle Bu Teaching Hospital Accra, Ghana","correspondingAuthor":false,"prefix":"","firstName":"George","middleName":"D.","lastName":"Brown","suffix":""},{"id":346821821,"identity":"98a3ffe8-e0d4-4664-9d81-88fc82df8299","order_by":3,"name":"Solomon Brookman","email":"","orcid":"","institution":"Bank Hospital, Accra, Ghana","correspondingAuthor":false,"prefix":"","firstName":"Solomon","middleName":"","lastName":"Brookman","suffix":""},{"id":346821822,"identity":"12770c38-11c5-4262-a284-d517ff6eaa65","order_by":4,"name":"Peter C. Ambe","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIiWNgGAWjYDADAwbmAyASivACZpgWtgSStfAYQBkEtJiz9x98XMFgF23O3vNNuqCAIXE7A/PGB/i0WPYcZjY8w5Ccu7Pn7DbpGQYMiTsb2IrxWmNwI5lNsoGBOXfDjdxt0jwG/3M3HOAxk8Cr5f5j9p8NDPW5G+6/eQbUwgDSYv4Dvy3MbIwNDIeBtvCwwbSY4dMB9EuysWSDwXGgX9KMrYFa6jccZivG6zBz9oMPPzZUVOduZz/88DbPHwZjg+PNGz/gdRgSCQXMeJ1FOKJHwSgYBaNgFDAwAAALnkVkgGg/hgAAAABJRU5ErkJggg==","orcid":"","institution":"Witten/Herdecke University","correspondingAuthor":true,"prefix":"","firstName":"Peter","middleName":"C.","lastName":"Ambe","suffix":""},{"id":346821823,"identity":"3a0f4ea3-9351-4678-ad76-bebf9fb2fb86","order_by":5,"name":"Kwabena Agbedinu","email":"","orcid":"","institution":"Komfo Anokye Teaching Hospital, Kumasi, Ghana","correspondingAuthor":false,"prefix":"","firstName":"Kwabena","middleName":"","lastName":"Agbedinu","suffix":""}],"badges":[],"createdAt":"2024-08-25 12:27:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4972660/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4972660/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12893-024-02686-8","type":"published","date":"2025-01-23T15:57:11+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":65702138,"identity":"f103d11f-c634-4207-91b1-90144014d96d","added_by":"auto","created_at":"2024-10-01 12:36:53","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":198821,"visible":true,"origin":"","legend":"\u003cp\u003ea: Incision and Release of Collection\u003c/p\u003e\n\u003cp\u003eb: Gentle Debridement with a Mosquito Clamp\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4972660/v1/0e7a44c723f2ff29345d549e.png"},{"id":65702142,"identity":"363f1167-eb48-4819-9c26-8a572a1df7a8","added_by":"auto","created_at":"2024-10-01 12:36:59","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":229132,"visible":true,"origin":"","legend":"\u003cp\u003ea: Applying Cold Gauze to Healthy Skin\u003c/p\u003e\n\u003cp\u003eb: Day 7 Post-Op\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4972660/v1/2be2c0a7ed462810152abcdd.png"},{"id":65702139,"identity":"4ae80156-3b6d-4865-b787-68716b6e5be5","added_by":"auto","created_at":"2024-10-01 12:36:53","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":176941,"visible":true,"origin":"","legend":"\u003cp\u003ea: Extensive Disease - Before Laser Treatment\u003c/p\u003e\n\u003cp\u003eb: Extensive Disease - After 2 Laser Sessions\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4972660/v1/9302813712f3b5c9b03be01d.png"},{"id":65702140,"identity":"5277e6ea-9e22-488f-a54b-259f6a29fe24","added_by":"auto","created_at":"2024-10-01 12:36:53","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":344657,"visible":true,"origin":"","legend":"\u003cp\u003ea: Extensive Disease (2) - Before Laser Treatment\u003c/p\u003e\n\u003cp\u003eb: Extensive Disease (2) - After 2 Laser Sessions\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4972660/v1/8e5cab47bbe4f6b4d68e7cb0.png"},{"id":74858326,"identity":"570c6d2e-9cfe-4091-8b21-f1f38a32f2e6","added_by":"auto","created_at":"2025-01-27 16:08:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1684037,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4972660/v1/71ea198a-298e-4a4d-861c-610b76b2ed77.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Minimally invasive management of Hidradenitis suppurativa using a 1470nm diode laser. A step-by-step description of our technique.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHidradenitis suppurativa (HS) is a chronic, recurrent, inflammatory condition involving the apocrine glands around the axilla (armpit), breast, groin, perineum and perianal regions \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. The condition most commonly affects young individuals from adolescence to early 40s \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. The disorder is thought to have a multi-factorial genesis with both genetic and epigenetic predispositions. The genetic aspect is backed by its occurrence in specific families with the involvement of many generations, thus supporting a possible autosomal dominant inheritance pattern \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Epigenetic aspects of HS constitute well-recognized association with the use of nicotine, obesity and diabetes. Some authors see HS as an autoimmune disorder, like inflammatory bowel disease \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe clinical spectrum of presentation is characterized by a chronic, recurrent and eventually progressive behavior, which is best described using the Hurley classification \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. According to this classification, and its different modifications, grade I disease is characterized by inflammatory, isolated nodules. Left untreated, these nodules may develop into fistulae, some of which get connected (Hurley grade II) \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. In an attempt to control the recurrent inflammation, scars eventually develop leading to a disfiguring picture (Hurley grade III) \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe diagnosis of HS is easily made per visualization \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. The three primary clinical features that support a diagnosis of Hidradenitis Suppurativa (HS) are:\u003c/p\u003e \u003cp\u003eTypical lesions: These include multiple deep-seated inflamed nodules, tombstone comedones, skin tunnels, abscesses, and/or fibrotic scars.\u003c/p\u003e \u003cp\u003eTypical locations: The lesions commonly occur in the axillae, groin, and inframammary areas, often presenting with a bilateral distribution.\u003c/p\u003e \u003cp\u003eRelapses and chronicity: The condition is characterized by recurring episodes and chronicity\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Although histopathology is not routinely needed, it should be considered in selected cases to rule out malignancy, e.g. squamous cell cancer \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Inspection of all predilection sites should be done in all patients suspected of or presenting with HS \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe management of HS should be multidisciplinary including both conservative or medical strategies and surgery \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Many international guidelines suggest a stepwise, grade-guided treatment algorithm including topical and systematic antibiotics, hormone-directed strategies, immune modulation and surgery \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe surgical strategy may range from a limited procedure like deroofing to extensive procedures like wide excision and fecal deviation with or without plastic reconstruction \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. The laser techniques constitute an item within the surgical armamentarium \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. The aim of this manuscript is to describe our technique of minimally invasive management of HS using a diode laser and to discuss this technique with respect to available literature.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis is a technical manuscript demonstrating our technique for laser\u0026ndash;assisted management of HS.\u003c/p\u003e \u003cp\u003eWe use a diode laser (Biolitec, Germany) with a wavelength of 1470nm for this indication. The depth of the sinus/tract dictates the amount of energy required. Our preference is to use 8 Watts for deep lesions and 5 Watts for shallow lesions. The laser energy is emitted at the tip of the probe in a circular fashion leading to denaturation of the proteins along the inflammatory tracts. This combined with gentle compression causes the tract to collapse and close. The laser penetrates the skin to selectively target and thermally destroy the follicular unit and organized inflammatory lesions within the superficial to mid-dermis\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. The procedure can be performed with general or local anesthesia as needed. The pathologic lesion is punctured and gently curetted. Attention must be paid to the size of the debriding instrument to prevent dilating the tract. Irrigation can be done in selected cases.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe following seven points should be considered when managing these patients:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. Draining all collections\u003c/strong\u003e: This is best achieved via a small incision at the apex of the collection prior to laser application. In cases with large collections and purulent secretion, laser surgery should be omitted. A gentle debridement of the tract may be performed. Irrigation is optional (Figures 1a \u0026amp; 1b).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Minimalize Tissue Damage:\u003c/strong\u003e This is achieved by making small incisions for drainage and by regulating the amount of laser energy applied to the tissue.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Protect Healthy Skin:\u003c/strong\u003e Superficial tracts within the subcutis may be covered just by a thin skin layer. This healthy skin should be protected from thermal damage via reducing the amount of laser energy applied and by applying a wet/cold gauze on the area during treatment (Figure 2a).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Control Risk Factors:\u003c/strong\u003e Smoking is a relevant risk factor for HS and quitting smoking may significantly influence the course of HS and treatment success.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5. Multidisciplinary Approach:\u003c/strong\u003e This includes but is not limited to the use of prolonged antibiotics, antihormonal therapy and biologics.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6. Close Follow-Up:\u0026nbsp;\u003c/strong\u003eThe chronic and recurrent nature of HS requires a close follow-up. (Figure 2b: Day 7 Post-Op)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e7. Patience:\u0026nbsp;\u003c/strong\u003eHealing post-op may take some time.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe surgery can be performed both under general or local anesthesia; even as an outpatient procedure. Postoperative wound dressing is done with a simple gauze. Postoperative pain is minimal and return to work is possible on Post-Op Day 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eExtensive disease usually requires more than one treatment session and additional treatment such as the use of biologics (Figures 3 - 4).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOver many decades the surgical management of HS has included procedures from limited local procedures like incision and drainage and deroofing to more extensive resections, with additional procedures like creating a stoma for fecal deviation. Some of these procedures led to excellent control at high costs for the patients with regards to risk of morbidity and quality of life. Thus, the need for less invasive surgical options with similar disease control became apparent.\u003c/p\u003e \u003cp\u003eThis manuscript presents our technique of performing laser surgery for patients with HS. This technique uses a well-defined amount of laser energy to destroy the epithelial lining of sinuses and tracts seen in patients with HS. This results in denaturization of proteins in the sinuses and tracts, which subsequently collapse and close secondary to the adhesive effect of the denaturized proteins.\u003c/p\u003e \u003cp\u003eThe use of laser in the management of HS is a well-recognized approach that has been stated in numerous treatment recommendations and guidelines. In the 2016 European guidelines for HS, Laser treatment was recommended for Hurley II and III \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Laser treatment in these guidelines reached a strong recommendation due to the high evidence level from the randomized controlled trial by Tierney et al using the Nd:YAG laser \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn recent years, more appealing data has been reported for the use of laser technology in HS. While some of this data is related to the effect of hair removal in patients with HS, there is nonetheless increasing experience with the use of this modality to manage this rather challenging pathology \u003csup\u003e\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOur experience with laser-associated treatment of patients with HS is similar to findings from the current literature. However, the multifaceted nature of Hydradenitis warrants a multidisciplinary approach. Therefore, we routinely use a combination of treatment options in the management of our patients. Our standard algorithm is to combine laser with a long course of antibiotics in patients with Hurley stages I and II and to escalate to a biologic in patients who are unresponsive to and do not tolerate antibiotics \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Also, we recommend biologics in patients with extensive disease and those with Hurley stage III \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. We have observed so far that almost all our patients with stage I would need just a single laser intervention for good control. Patients with stages II and III may require repeated intervention. In such cases, we recommend repeated surgeries at 6\u0026ndash;8 week intervals.\u003c/p\u003e \u003cp\u003eWhile most data in the literature report on the use of either the CO\u003csub\u003e2\u003c/sub\u003e or the Nd:YAG laser, our experience is based on the diode laser. Thus, a direct comparison may be questionable.\u003c/p\u003e \u003cp\u003eIrrespective of the above limitation, the minimally invasive laser surgery for HS largely preserves the tissue. Laser surgery has been shown to significantly reduce postoperative pain and morbidity, leading to an early return to work and a better quality of life. It would be interesting to study the positive experiences reported in this manuscript in a prospective setting with more patients.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eLaser-based management of hidradenitis suppurativa is a promising surgical option in the multidisciplinary treatment of this difficult pathology. The minimally invasive nature of laser surgery, especially tissue preservation, is a strong argument for the role of this technique in the management of this chronic, recurrent condition.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHidradenitis suppurativa\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eMany thanks to Biolitec for material support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003eWas not necessary blinded images without patient´s data were used\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: \u0026nbsp;All patients consented on the use of anonymized images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e: Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors´contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePCA conceptualized the manuscript. \u0026nbsp;NKDB, PCA, KA and PKK designed the manuscript. GDB, SB, PKK, PCA and KA performed literature research for the manuscript. NKDB drafted the manuscript. PKK and KA edited the manuscript. All authors read and approved the final draft.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLuporini RL, Frizol SM, Segantini MJ, Pereira LD, Fontanella AP, F\u0026eacute;res O. Hidradenitis suppurativa perineal and perianal. Benign Anorectal Disorders-An Update. IntechOpen; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoi E, Ooi XT, Chandran NS. Hidradenitis suppurativa in pediatric patients. J Am Acad Dermatol. 2022;86(1):140\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJfri A. Hidradenitis Suppurativa: The Study of Natural History, Genetics, Comorbidities and Impact on Patient\u0026rsquo;s Life. McGill University (Canada); 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eConstantinou CA, Fragoulis GE, Nikiphorou E. Hidradenitis suppurativa: infection, autoimmunity, or both? Ther Adv Musculoskelet Dis. 2019;11:1759720X19895488.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZouboulis CC, Benhadou F, Byrd AS, et al. What causes hidradenitis suppurativa?\u0026mdash;15 years after. Exp Dermatol. 2020;29(12):1154\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRevuz J. Hidradenitis suppurativa. J Eur Acad Dermatol Venereol. 2009;23(9):985\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVinkel C, Thomsen SF. Hidradenitis suppurativa: causes, features, and current treatments. J Clin Aesthet Dermatol. 2018;11(10):17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMargesson LJ, Danby FW. Hidradenitis suppurativa. Best Pract Res Clin Obstet Gynaecol. 2014;28(7):1013\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWortsman X. Diagnosis and treatment of hidradenitis suppurativa. JAMA. 2018;319(15):1617\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohn H, Manoloudakis N, Sinclair JS. A systematic review of the use of lasers for the treatment of hidradenitis suppurativa. J Plast Reconstr Aesthetic Surg. 2016;69(10):1374\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLapins J, Ye W, Nyr\u0026eacute;n O, Emtestam L. Incidence of cancer among patients with hidradenitis suppurativa. Arch Dermatol. 2001;137(6):730\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCollier EK, Parvataneni RK, Lowes MA, et al. Diagnosis and management of hidradenitis suppurativa in women. Am J Obstet Gynecol. 2021;224(1):54\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShukla R, Karagaiah P, Patil A, et al. Surgical treatment in hidradenitis suppurativa. J Clin Med. 2022;11(9):2311.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHendricks AJ, Hsiao JL, Lowes MA, Shi VY. A comparison of international management guidelines for hidradenitis suppurativa. Dermatology. 2021;237(1):81\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOvadja ZN, Bartelink SAW, Hadi K, Van De Kar AL, Van Der Horst CMAM, Lapid O. A multicenter analysis of wide excision and reconstruction for severe anogenital hidradenitis suppurativa. Ann Plast Surg. 2021;86(2):193\u0026ndash;200.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTierney E, Mahmoud BH, Hexsel C, Ozog D, Hamzavi I. Randomized control trial for the treatment of hidradenitis suppurativa with a neodymium-doped yttrium aluminium garnet laser. Dermatol Surg. 2009;35(8):1188\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXu LY, Wright DR, Mahmoud BH, Ozog DM, Mehregan DA, Hamzavi IH. Histopathologic study of hidradenitis suppurativa following long-pulsed 1064-nm Nd: YAG laser treatment. Arch Dermatol. 2011;147(1):21\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGulliver W, Zouboulis CC, Prens E, Jemec GBE, Tzellos T. Evidence-based approach to the treatment of hidradenitis suppurativa/acne inversa, based on the European guidelines for hidradenitis suppurativa. Rev Endocr Metab Disord. 2016;17(3):343\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLinds\u0026oslash; Andersen P, Riis PT, Thorlacius L, et al. Intense pulsed light treatment for hidradenitis suppurativa: a within-person randomized controlled trial. Eur J Dermatology. 2020;30:723\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaza\u0026ntilde;a TG, D\u0026iacute;az LVB, S\u0026aacute;nchez JIM, Nasarre IQ, Gilaberte Y. Systematic review of light-based treatments for hidradenitis suppurativa. Actas Dermo-Sifiliogr\u0026aacute;ficas (English Edition). 2020;111(2):89\u0026ndash;106.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Rappard DC, Mekkes JR, Tzellos T. Randomized controlled trials for the treatment of hidradenitis suppurativa. Dermatol Clin. 2016;34(1):69\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hidradenitis suppurativa, Hidradenitis, Acne inversa, laser therapy, diode laser, dermatology, laser surgery","lastPublishedDoi":"10.21203/rs.3.rs-4972660/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4972660/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe management of hidradenitis suppurativa (HS) requires a multidisciplinary approach to ensure sustainable treatment results, especially in the advanced stages. Traditionally, deroofing and wide excision represented commonly employed surgical techniques. Due to the recurrent nature of HS, tissue preservation should be a relevant aspect of the surgical management. The aim of this manuscript is to demonstrate the use of a diode laser for the management of different stages of HS, paying attention on tissue preservation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is a technical manuscript demonstrating our technique for laser–assisted management of HS. A diode laser with a wavelength of 1470nm was used for this indication. The depth of the sinus/tract dictates the amount of energy required. Our preference is to use 8 Watts for deep lesions and 5 Watts for shallow lesions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe following 7 critical steps are important to achieve an optimal result with this technique:\u003c/p\u003e\n\u003cp\u003eDrain all collections, minimalize tissue damage, protect healthy skin, control risk factors, adopt a multidisciplinary approach, follow-up closely, and be patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLaser-based management of hidradenitis suppurativa is a promising surgical option in the multidisciplinary treatment of this difficult pathology. The minimally invasive nature of laser surgery, especially tissue preservation, is a strong argument for the role of this technique in the management of this chronic, recurrent condition.\u003c/p\u003e","manuscriptTitle":"Minimally invasive management of Hidradenitis suppurativa using a 1470nm diode laser. A step-by-step description of our technique.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-01 12:36:47","doi":"10.21203/rs.3.rs-4972660/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-29T12:01:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-28T14:15:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-28T14:13:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2024-08-25T12:25:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1c413014-226b-47bc-aec1-6e50d2484ca8","owner":[],"postedDate":"October 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-27T16:00:04+00:00","versionOfRecord":{"articleIdentity":"rs-4972660","link":"https://doi.org/10.1186/s12893-024-02686-8","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2025-01-23 15:57:11","publishedOnDateReadable":"January 23rd, 2025"},"versionCreatedAt":"2024-10-01 12:36:47","video":"","vorDoi":"10.1186/s12893-024-02686-8","vorDoiUrl":"https://doi.org/10.1186/s12893-024-02686-8","workflowStages":[]},"version":"v1","identity":"rs-4972660","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4972660","identity":"rs-4972660","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}