Hidradenitis Suppurativa Medical Procedures

Surgery for hidradenitis suppurativa (HS) ranges from quick in-office procedures that take minutes to extensive excisions requiring weeks of wound care, and the right choice depends heavily on disease severity and location. Advances in ultrasound mapping, laser technology, and the combination of biologics with surgery have expanded the procedural toolkit considerably over the past decade. The procedure a surgeon recommends for you will hinge on whether you have isolated flare-ups or widespread, interconnected tunnels beneath the skin.

Why Procedures Are Part of the Treatment Plan

HS is a chronic inflammatory condition of the hair follicles and surrounding tissue. It produces painful nodules, abscesses, and, over time, tunnels (also called sinus tracts) that connect under the skin. Medications alone can reduce inflammation, but once tunnels and scarring have formed, no drug can undo the structural damage. That is where procedures come in. Surgery can be effective across the severity spectrum, from early-stage disease through the most advanced cases, thanks to better understanding of how HS behaves and improvements in reconstructive techniques.¹

Intralesional Injections for Acute Flares

When a single HS nodule or abscess is acutely inflamed and painful, the fastest intervention is often an injection of a corticosteroid directly into the lesion. Triamcinolone acetonide, at concentrations of 10 to 40 mg per mL, reduces pain, redness, and drainage often within 48 hours, and can be repeated every two weeks if needed.² A multicenter retrospective study found that intralesional corticosteroid injections are useful for controlling both acute and stubborn lesions that are not responding to other treatments.³

These injections do not treat the underlying disease process. They buy time by calming a flare, which can make the difference between functioning through your week and being in too much pain to sit. They are also sometimes used to shrink an inflamed lesion before a planned surgical procedure, making the surgery itself cleaner and more controlled.

Incision and Drainage Versus Deroofing

Incision and drainage (I&D) is the emergency-room standby: a doctor opens up an abscess and lets the pus drain. It provides immediate pain relief, but because I&D does not remove the lining of the abscess cavity or any tunnels feeding it, the lesion almost always returns. Deroofing takes a step further. The surgeon removes the “roof” of a tunnel or abscess, exposing the base, and then lets the wound heal from the bottom up (secondary intention healing). A systematic review and meta-analysis found estimated average recurrence rates of about 22% for local excision procedures and about 27% for deroofing, compared with roughly 13% for wide excision.⁴

Deroofing is popular for individual tunnels and moderately sized lesions because it can be done under local anesthesia in an office or outpatient setting, leaves less scarring than wide excision, and still has a reasonable success rate. It is best suited for localized disease rather than large areas where tunnels branch in many directions. If you have just one or two persistent tracts that keep draining, deroofing is often the first surgical step a dermatologist will suggest.

Wide Excision

For more advanced disease, wide excision is the workhorse procedure. The surgeon removes the entire affected area of skin, subcutaneous tissue, and tunnels with a healthy margin of tissue around the visible disease. The goal is to leave nothing behind that could seed a recurrence. A systematic review comparing partial excision (removing just the visible disease) with wide excision found recurrence rates of about 26% and 5%, respectively.⁵ That gap is stark, and it is the main reason wide excision is often recommended as a first-line surgical therapy, especially for people with severe or repeatedly recurrent disease.

One challenge with wide excision has historically been knowing exactly where the disease extends beneath the skin. Tunnels are not always visible on the surface. Recent work using ultra-high frequency ultrasound to map lesions before surgery has shown promising results. In one study using this presurgical mapping technique with wide local excision and secondary intention healing, only 10% of patients experienced clinical relapse over a 22-month follow-up, translating to a 90% total remission rate.⁶ Preoperative ultrasound mapping appears to help surgeons identify and remove tissue they might otherwise have missed, which contributes to the low recurrence rates and fewer postoperative complications.⁷

Wide excision significantly improves patients’ quality of life and pain. A prospective study found that dermatology-specific quality of life scores improved from about 14.5 at baseline to about 5.8 at six months after surgery, with pain scores dropping from about 3.7 to 0.8.⁸ Another study found significant improvement across multiple dimensions including walking ability, self-care, routine activities, pain, and mental health at six months postoperatively.⁹

How the Wound Gets Closed

After wide excision, you are left with a significant wound, and how it is closed matters both for healing time and for the chance the disease comes back. The options generally fall into four categories: letting it heal on its own (secondary intention), closing it directly with stitches (primary closure), covering it with a skin graft, or rotating nearby tissue over the wound (a flap).

A systematic review and meta-analysis comparing these approaches found the following recurrence rates: flaps at about 12%, skin grafts at about 18%, primary closure at about 25%, and secondary intention healing at about 28%.¹⁰ Flaps had the lowest recurrence in that analysis, though the choice is not always straightforward. There is a logical argument for split-thickness skin grafts, because HS involves hair follicles and sweat glands, and a split-thickness graft lacks those structures, potentially reducing the chance of new disease forming in the grafted area.¹¹

Secondary intention healing remains common despite its higher recurrence numbers, partly because it avoids a second surgical site (you do not need to harvest skin from elsewhere) and partly because many surgeons feel it is the safest option in a wound bed that may still harbor bacteria. The tradeoff is time: healing by secondary intention after wide excision can take anywhere from 8 weeks to 16 months, and physical therapy may be needed afterward to prevent joint stiffness, particularly when the excision is in the armpit or groin.¹²

Negative Pressure Wound Therapy After Surgery

For large or heavily contaminated wounds, negative pressure wound therapy (NPWT), sometimes known by the brand name wound-VAC, has become a valuable bridge between excision and final healing. A sealed dressing applies gentle suction to the wound, which helps increase blood flow, promote the formation of new tissue, reduce bacterial load, and shrink the wound’s overall size.¹³ One approach uses an internal vacuum-assisted closure device as a bridge between excision and delayed primary closure, allowing even large and heavily contaminated wounds to be closed without recurrence.¹⁴

NPWT is not something you do at home in the early days. The device is placed in the operating room or clinic, and dressing changes require a healthcare provider. But it has made surgeons more confident about excising larger areas, because the wound management afterward is more reliable than traditional packing alone.¹⁵

CO2 Laser for Tunnels and Sinus Tracts

Carbon dioxide laser excision has carved out a niche for treating HS tunnels. The laser precisely cuts away diseased tissue, and the surgeon can then vaporize the base and margins of the wound to destroy any remaining disease. In one study of 61 patients undergoing 154 CO2 laser procedures, only two patients experienced recurrence within the treated area, and average healing time was about 8.8 weeks by secondary intention.¹⁶

A comparative multicenter study found that 90% of patients in the CO2 laser group achieved complete tunnel healing at six months, versus 80% in the surgical deroofing group.¹⁷ Data from an Asian cohort found a recurrence rate of about 9% per procedure after CO2 laser deroofing.¹⁸ The laser’s advantage is its precision: it can follow the contours of a tunnel without removing large swaths of surrounding healthy tissue, which is especially useful for disease in sensitive areas like the groin or near joints where preserving tissue matters for function.

Nd:YAG Laser for Follicular Destruction

While CO2 lasers are used to cut and vaporize existing disease, the long-pulsed Nd:YAG laser works differently. It targets hair follicles themselves, destroying them through heat. Since HS is fundamentally a disease of the hair follicle, reducing the number of follicles in affected areas can reduce future flares. This approach is considered most useful for earlier-stage disease, where it reduces hair follicles, sebaceous glands, and the bacterial load that contributes to inflammation.¹⁹

A controlled clinical study found that after four months of Nd:YAG laser treatment, disease activity improved by about 73% on the treated side compared with roughly 23% on the untreated control side. Tissue samples confirmed destruction of hair follicles in the treated areas.²⁰ A meta-analysis pooling data from multiple laser hair removal modalities found a large reduction in disease severity scores favoring treatment.²¹

Nd:YAG treatment typically requires multiple sessions, usually four to six spaced a month apart, and works best as a way to reduce flare frequency in a specific area rather than as a cure for established tunnels. If you already have extensive tunnel disease, follicle destruction will not address the existing damage, but it may help prevent new lesions from forming nearby.

Combining Biologics With Surgery

One of the more meaningful shifts in HS management over the past decade is the recognition that surgery and biologic medications work better together than either alone. Biologics like adalimumab, secukinumab, and bimekizumab suppress the inflammatory pathways driving HS, and combining them with surgical procedures has been associated with improved outcomes compared to biologic therapy alone, including higher clinical response rates, greater reductions in pain, and better quality of life scores.²² One study of patients with recalcitrant HS found that adjuvant biologic therapy after radical surgical resection was associated with lower recurrence rates and a longer disease-free interval.²³

A practical worry for both patients and surgeons is whether immunosuppressive biologics increase the risk of wound infections or other complications after surgery. The SHARPS randomized clinical trial found no increased risk of postoperative wound infection, complications, or hemorrhage in patients receiving adalimumab compared to placebo around the time of surgery.²⁴ A review of the broader literature found that the vast majority of studies showed no difference in surgical outcomes between patients on biologics and those not taking them, though a small number noted longer wound healing times in the biologic group, possibly due to more severe disease in those patients.²⁵

What Drives Recurrence After Surgery

Even with the best procedure and reconstruction, HS can come back. Recurrence is one of the most frustrating aspects of the disease. Research has identified two broad categories: recurrence at the same site and new disease at a different location. An older but frequently cited study found that recurrence at the original site usually results from incomplete removal of affected tissue or from an unusually wide distribution of the glands involved. Factors like obesity, local pressure, and skin moisture also played a role in some patients. About a quarter of patients developed new HS at a completely different body site after surgery.²⁶

This distinction matters because it shapes expectations. No surgery can prevent new disease from forming in an area that was never operated on, because the underlying inflammatory tendency is systemic. What surgery can do, particularly wide excision with adequate margins, is achieve durable clearance at the specific sites that are treated. Managing the systemic component with medications, weight management, and smoking cessation addresses the other half of the equation.

Pain Control During Procedures

HS lesions are extraordinarily painful, and the skin around them is often chronically inflamed, making local anesthesia less effective than it would be in healthy tissue. For small procedures like I&D or deroofing, local anesthetic injections are standard but may need to be supplemented. Wider excisions are typically performed under general anesthesia or regional nerve blocks. A case report described a modified regional nerve block technique for axillary HS that eliminated the need for any local anesthetic during incision and drainage, suggesting that regional block approaches may offer better pain control for procedures in difficult-to-numb areas.

Procedures in Younger Patients

HS can begin in adolescence, and procedural options look somewhat different in younger patients. Punch debridement for small nodules and tissue-sparing deroofing for established tracts can both be performed in pediatric patients with careful attention to pain management.²⁷ A newer minimally invasive approach called pediatric endoscopic hidradenitis treatment uses a small camera and instruments to clean out disease through tiny incisions. Early reports describe a painless postoperative period and excellent results.²⁸

The emotional and social toll of HS on teenagers is considerable, and the threshold for procedural intervention tends to be lower than it might be in adults simply because of how much the disease can affect school attendance, social life, and self-image during formative years. At the same time, the growing skeleton and concern about scarring in areas near joints make tissue-sparing approaches especially appealing in this age group.

Procedures During Pregnancy

HS often worsens during pregnancy, and several medications commonly used to manage it are off-limits during gestation. Procedural therapies become particularly important in this setting because they can address acute disease without systemic drug exposure. While certain HS medications like tetracyclines and spironolactone are contraindicated during pregnancy, procedural therapies remain an available option alongside select topicals, systemic antibiotics, and some biologics.²⁹ Minor procedures like I&D and deroofing can be performed safely under local anesthesia during pregnancy when a flare is causing severe pain or functional limitation, though elective wide excisions are generally deferred until after delivery when possible.

Choosing Between Procedures

The decision about which procedure fits depends on several intersecting factors. Disease stage is the most obvious: a single draining abscess calls for a different approach than an entire armpit riddled with interconnecting tunnels. Location matters too. The groin and perianal areas present unique challenges for wound closure and hygiene during healing, and tissue-sparing options may be preferred to avoid prolonged disability. A history of prior recurrences at the same site pushes the conversation toward wider excision with careful preoperative imaging, since the previously operated area may harbor residual disease that was not removed the first time.

Your overall health profile feeds into the decision as well. If you smoke, many surgeons will strongly encourage cessation before major excisional surgery because smoking impairs wound healing and is independently associated with HS severity. If you are managing HS with a biologic, the evidence now suggests that you do not necessarily need to pause it around the time of surgery, though your care team will want to coordinate the timing. And if you have involvement at multiple body sites, a staged approach, operating on one area at a time, is typical to avoid overwhelming healing capacity.

There is no single best procedure for HS. The research on recurrence, quality of life, and complications paints a consistent picture: wider and more thorough removal of diseased tissue produces lower recurrence rates, and combining surgery with systemic anti-inflammatory treatment yields better outcomes than either strategy alone. The trend in the field is toward earlier surgical intervention rather than waiting until the disease has progressed to its most severe stage, paired with medical therapy to keep the underlying inflammation in check.