Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that causes painful bumps under the skin.
It often develops in places where the skin rubs together, such as the armpits, groin, abdomen, buttocks and breasts. These bumps can rupture, forming draining wounds, scars, and tunnels (sinus tracts) under the skin.
The pain, discomfort, and flare-ups of HS symptoms can take an emotional toll, affecting your self-esteem and overall quality of life. Treatment options such as medication and lifestyle changes can help manage HS symptoms. Sometimes surgery may be necessary.
Surgical options may include removing the affected tissue, draining an abscess (a pocket of pus under the skin), or more extensive procedures that can help prevent future breakouts in the affected area. Surgical treatment can help relieve pain and improve mobility and quality of life for people with HS.
When determining whether surgery is necessary, health care providers consider several factors, including the severity of the condition, its impact on daily life activities, and whether other treatments are effectively managing symptoms.
Using the Hurley Clinical Staging System, healthcare providers can determine the severity of the condition and determine whether surgical intervention is needed. The three stages of HS are:
- Phase 1: At this stage, HS is mild and usually involves isolated single lumps or abscesses that heal without scarring or sinus tracts (tunnel-like formations under the skin).
- 2nd phase: HS is moderate, which means you have recurring abscesses, scarring, and sinus tract formation. These features can affect daily activities and cause permanent discomfort.
- 3rd stage: This most advanced stage of HS involves extensive interconnected sinus tracts and widespread scarring or inflammation of the skin.
In addition to stage, health professionals take into account the frequency and severity of symptoms and the degree of tissue damage. Surgery is generally the most appropriate when drugs alone are not effective in treating HS.
There are several surgical treatment options for hidradenitis suppurativa, ranging from simple procedures with quick recovery times to more extensive surgeries to address more complex or advanced cases. The type of surgery your healthcare provider recommends will depend on your stage of HS, the parts of your body affected, and the number of bumps, tunnels, or abscesses you have.
1. Incision and drainage
Incision and drainage are minor surgical procedures for treating recurrent or severe abscesses.
Your health care provider will numb the affected area with a local anesthetic, which means you will remain awake, but you should not feel any pain or discomfort during the procedure. They will make a small incision in the skin to drain the pus from the abscess and pack the area with gauze to promote healing and prevent infection.
The incision and drainage procedure is relatively quick; most people can go home the same day.
Although this procedure reduces inflammation in the short term and provides almost immediate pain relief, it is not a long-term solution for HS. Recurrence rates after incision and drainage are nearly 100%. This method can temporarily manage symptoms or serve as a preparatory step before a more comprehensive surgical procedure.
2. Deroofing
Deroofing is a simple, minimally invasive surgical procedure to treat sinus tracts and persistent lesions or abscesses in people with stage 1 or 2 HS. Before the procedure, your healthcare provider will numb the area with a local anesthetic to prevent pain or discomfort.
During the procedure, the surgeon opens the tunnels and removes the top layer, or “roof,” while leaving the bottom layer intact. This preserves structures in the skin, such as sweat glands and hair follicles, helping the wound to heal more quickly.
Healing time for deroofing varies, depending on the size of the treated area. Full recovery occurs within 3-8 weeks for most people. You will have a scar from the site of the surgical incision; most scars tend to shrink to 25-30% of the original size of the surgical incision.
Research shows that deroofing is very effective, and about 90% of people who undergo the procedure say they are satisfied with the results. While some people (about 17%) develop recurrent abscesses or sinus tracts in the months following the procedure, most do not experience recurrence in the treated area.
3. Wide local excision
Wide local excision (VLE) is the gold standard of surgical treatment for severe HS (Hurley stage 3). This surgery involves removing the deep layers of affected skin and fat to remove any lesions, tunnels and scar tissue that affect a larger area of skin. VLE is very efficient; only about 5% of people who undergo VLE experience recurrence of symptoms in the treated area.
During this procedure, you will sleep under general anesthesia. Depending on how much skin and tissue your surgeon removes, they may be left open to heal or closed with sutures (stitches) or skin grafts.
You may need a short stay in the hospital for post-surgical care and, once you are discharged, frequent follow-up visits with your doctor to monitor the progress of your treatment. Recovery from a wide local excision can take 1-3 months, depending on how much skin is removed.
4. Skin flaps and grafts
Skin flaps and grafts are reconstructive techniques that healthcare professionals sometimes use to close wounds during VLE surgery. Skin flaps involve repositioning nearby healthy tissue to cover the wound, while grafts use skin harvested from another part of the body.
If you have a wide local buttock excision, your healthcare provider may remove healthy skin from the inner thigh to graft it over the excised area.
After undergoing VLE involving a flap or graft, your healthcare provider will give you post-operative wound care instructions to ensure proper healing. This usually involves keeping the area clean and dry, avoiding activities that may stress the wound(s), and elevating the wound (if possible) to reduce swelling.
5. CO2 laser therapy
Carbon dioxide (CO2) laser therapy is a minimally invasive treatment option for recurrent or extensive HS lesions with scarring and sinus tracts. This procedure uses focused laser energy to destroy and remove diseased tissue while leaving healthy surrounding skin intact. After removing the affected tissue, health care professionals close the treated area with stitches or leave it open to heal naturally.
Healing usually takes about four weeks, and the recurrence rate ranges from 11-29%. People who undergo CO2 laser therapy report less postoperative pain and better cosmetic results (ie, less scarring) compared to other surgical treatment methods.
Although less suitable for extensive or advanced disease, CO2 laser therapy can be an excellent option for localized HS in people seeking minimally invasive treatment.
Although surgery can effectively manage hidradenitis suppurativa, it is not the only option available. Many people benefit from non-surgical treatments that help reduce inflammation, relieve pain and itching, and prevent inflammation. Treatment plans for mild to moderate HS may include nonsurgical options such as:
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- Local treatments: Medicated creams and ointments that contain antibiotics, corticosteroids, or retinoids can reduce inflammation, bumps, and bacterial growth on the skin to treat or prevent skin infections.
- Oral antibiotics: Antibiotics can help reduce the bacteria that cause inflammation and flare-ups.
- Biological therapies: Biologics such as Humira (adalimumab) and Cosentik (secukinumab) are injectable drugs that target the immune system to reduce inflammation.
- Steroid injections: Corticosteroid injections can help reduce inflamed lumps and provide quick relief from pain and swelling.
- Hormonal therapies: People who experience flare-ups due to hormonal fluctuations during their menstrual cycle may benefit from taking birth control pills.
- Lifestyle changes: Using gentle antimicrobial soaps, quitting smoking, and wearing loose-fitting clothing can help reduce friction and prevent skin irritation.
- Laser hair removal: Removing the hair follicles in the affected areas can help reduce the appearance of lumps and abscesses.
- Botox (botulinum toxin): Botox injections can help reduce sweat production, which can reduce the risk of infection, especially in areas prone to inflammation.
Living with hidradenitis suppurativa (HS) can be difficult, but effective treatments can help manage symptoms and reduce the impact the condition has on your daily life.
Surgery, including options such as deroofing, CO2 laser therapy, and wide local excision, can help treat moderate to severe HS and provide much-needed relief from symptoms.
If you’re living with HS, talk to your healthcare provider to discuss your treatment options and whether you’re a candidate for hidradenitis suppurativa surgery.