Surgical approaches in the management of hidradenitis suppurativa: Techniques, risks, and clinical outcomes
DOI:
https://doi.org/10.25251/96va0e34Keywords:
biologics, excision, hidradenitis suppurativa, laser therapy, surgical procedures, therapeuticsAbstract
Background: Hidradenitis suppurativa (HS) is a chronic, progressive, inflammatory dermatologic condition that affects intertrig-
inous areas with high concentrations of apocrine glands. Initial management is medical; however, surgical excision and wound
reconstruction are indicated for severe or refractory disease. This study evaluated current surgical techniques for HS and analyzed
their associated risks and reported outcomes.
Methods: A review of the literature was conducted to assess surgical approaches, including incision and drainage, deroofing, local
excision, wide excision, cryoinsufflation, and laser therapies. Reported complication and recurrence rates were analyzed.
Results: Wide excision is favored over less extensive techniques for Hurley stage II and III HS, with lower recurrence and compli-
cation rates. The estimated overall complication rate for surgical treatment is 11.1% (95% confidence interval [CI], 6.4%–16.9%),
and the estimated overall recurrence rate is 16.2% (95% CI, 9.1%–24.9%).
Conclusion: These findings support a more aggressive surgical approach when minimizing recurrence is a primary goal. Procedure
selection should be individualized based on patient lifestyle, comorbidities, disease location, and long-term efficacy. Further rigorous
research into emerging multidisciplinary therapies and surgical innovations is needed to establish an improved standard of care for HS.
References
1. Carranza, M.C., & Guevara, M.R. (2024). Advancements in Understanding and Management of Hidradenitis Suppurativa: Pathophysiology, Clinical Manifestations, and Therapeutic Interventions. International Journal of Medical Science and Clinical Research Studies.
2. Vinkel C, Thomsen SF. Hidradenitis Suppurativa: Causes, Features, and Current Treatments. J Clin Aesthet Dermatol. 2018 Oct;11(10):17-23. Epub 2018 Oct 1. PMID: 30519375; PMCID: PMC6239161.
3. Ovadja ZN, Schuit MM, van der Horst CMAM, Lapid O. Inter- and intrarater reliability of Hurley staging for hidradenitis suppurativa. Br J Dermatol. 2019 Aug;181(2):344-349. doi: 10.1111/bjd.17588. Epub 2019 Mar 14. PMID: 30585304; PMCID: PMC6850108.
4. Kelly G. and Prens E. P., Inflammatory mechanisms in hidradenitis suppurativa, Dermatologic Clinics. (2016) 34, no. 1, 51–58, https://doi.org/10.1016/j.det.2015.08.004, 2-s2.0-84961239292.
5. Nesbitt E, Clements S, Driscoll M. A concise clinician's guide to therapy for hidradenitis suppurativa. Int J Womens Dermatol. 2019 Dec 27;6(2):80-84. doi: 10.1016/j.ijwd.2019.11.004. PMID: 32258336; PMCID: PMC7105662.
6. Clemmensen O.J. Topical treatment of hidradenitis suppurativa with clindamycin. Int J Dermatol. 1983;22(5):325–328. doi: 10.1111/j.1365-4362.1983.tb02150.x.
7. Riis P.T., Boer J., Prens E.P., Saunte D.M., Deckers I.E., Emtestam L. Intralesional triamcinolone for flares of hidradenitis suppurativa (HS): a case series. J Am Acad Dermatol. 2016;75(6):1151–1155. doi: 10.1016/j.jaad.2016.06.049
8. Pascual J.C., Encabo B., Ruiz de Apodaca R.F., Romero D., Selva J., Jemec G.B. Topical 15% resorcinol for hidradenitis suppurativa: an uncontrolled prospective trial with clinical and ultrasonographic follow-up. J Am Acad Dermat. 2017;77(6):1175–1178. doi: 10.1016/j.jaad.2017.07.008.
9. Frost P., Weinstein G.D., Gomez E.C. Phototoxic potential of minocycline and doxycycline. Arch Dermatol. 1972;105(5):681–683.
10. Alhusayen R., Shear N.H. Scientific evidence for the use of current traditional systemic therapies in patients with hidradenitis suppurativa. J Am Acad Dermatol. 2015;73(5 Suppl 1):S42–S46. doi: 10.1016/j.jaad.2015.07.049.
11. Matusiak L., Bieniek A., Szepietowski J.C. Acitretin treatment for hidradenitis suppurativa: a prospective series of 17 patients. Br J Dermatol. 2014;171(1):170–174. doi: 10.1111/bjd.12884.
12. Kraft J.N., Searles G.E. Hidradenitis suppurativa in 64 female patients: retrospective study comparing oral antibiotics and antiandrogen therapy. J Cutan Med Surg. 2007;11(4):125–131. doi: 10.2310/7750.2007.00019.
13. van Rappard D.C., Leenarts M.F., Meijerink-van 't Oost L., Mekkes J.R. Comparing treatment outcome of infliximab and adalimumab in patients with severe hidradenitis suppurativa. J Dermatolog Treat. 2012;23(4):284–289. doi: 10.3109/09546634.2011.571657.
14. Tzanetakou V., Kanni T., Giatrakou S., Katoulis A., Papadavid E., Netea M.G. Safety and efficacy of anakinra in severe hidradenitis suppurativa: a randomized clinical trial. JAMA Dermatol. 2016;152(1):52–59. doi: 10.1001/jamadermatol.2015.3903
15. Scuderi N, Monfrecola A, Dessy L Medical and Surgical Treatment of Hidradenitis Suppurativa: A Review. Skin Appendage Disord. 2017. pp. 32pp. 95–110
16. Vellaichamy G, Braunberger T, Nahhas A et al. Surgical Procedures for Hidradenitis Suppurativa. Cutis. 2018;102(1):13–16.
17. Alikhan A, Sayed C, Alavi A et al. North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations. J Am Acad Dermatol. 2019;81(1):76–90. doi: 10.1016/j.jaad.2019.02.067.
18. Van der Zee H, Prens E. and Boer J. Deroofing: A tissue-saving surgical technique for the treatment of mild to moderate hidradenitis suppurativa lesions. J Am Acad Dermatol. 2010;63(3):475–480. doi: 10.1016/j.jaad.2009.12.018.
19. Blok J.L., Boersma M., Terra J.B., Spoo J.R., Leeman F.W.J., Van Den Heuvel E.R., Huizinga J., Jonkman M.F., Horváth B. Surgery under general anaesthesia in severe hidradenitis suppurativa: A study of 363 primary operations in 113 patients. J. Eur. Acad. Dermatol. Venereol. 2015;29:1590–1597. doi: 10.1111/jdv.12952.
20. Van Rappard D.C., Mooij J.E., Mekkes J.R. Mild to moderate hidradenitis suppurativa treated with local excision and primary closure. J. Eur. Acad. Dermatol. Venereol. 2012;26:898–902. doi: 10.1111/j.1468-3083.2011.04203.x.
21. Janse I., Bieniek A., Horváth B., Matusiak Ł. Surgical procedures in hidradenitis suppurativa. Dermatol. Clin. 2016;34:97–109. doi: 10.1016/j.det.2015.08.007.
22. Steele AW, Miller NF, Wallace SJ, Hume KM, Sommers CA, Simmons CJ, Murphy RX Jr. Hidradenitis Suppurativa: A Comparison of Institutional Experience and the Tracking Operations and Outcomes for Plastic Surgeons Registry. Plast Reconstr Surg. 2022 May 1;149(5):1216-1224. doi: 10.1097/PRS.0000000000009024. Epub 2022 Mar 18. PMID: 35311802.
23. Wortsman X., Moreno C., Soto R., Arellano J., Pezo C., Wortsman J. Ultrasound in-depth characterization and staging of hidradenitis suppurativa. Dermatol. Surg. 2013;39:1835–1842. doi: 10.1111/dsu.12329.
24. Hazen P.G., Hazen B.P. Hidradenitis suppurativa: Successful treatment using carbon dioxide laser excision and marsupialization. Dermatol. Surg. 2010;36:208–213. doi: 10.1111/j.1524-4725.2009.01427.x.
25. Madan V., Hindle E., Hussain W., August P.J. Outcomes of treatment of nine cases of recalcitrant severe hidradenitis suppurativa with carbon dioxide laser. Br. J. Dermatol. 2008;159:1309–1314. doi: 10.1111/j.1365-2133.2008.08932.x.
26. 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):1188-1198. doi:10.1111/j.1524-4725.2009.01214.x
27. Sidhom S, Petry SU, Ward R, Daveluy S. Treatment of hidradenitis suppurativa with 755-nm alexandrite laser hair removal: A randomized controlled trial. JAAD Int. 2024;16:239-243. Published 2024 Apr 24. doi:10.1016/j.jdin.2024.04.005
28. Lapins J., Sartorius K., Emtestam L. Scanner-assisted carbon dioxide laser surgery: A retrospective follow-up study of patients with hidradenitis suppurativa. J. Am. Acad. Dermatol. 2002;47:280–285. doi: 10.1067/mjd.2002.124601
29. Ritz JP, Runkel N, Haier J, Buhr HJ. Extent of surgery and recurrence rate of hidradenitis suppurativa. Int J Colorectal Dis 1998;13:164-8.
30. Mehdizadeh A, Hazen PG, Bechara FG, Zwingerman N, Moazenzadeh M, Bashash M, Sibbald RG, Alavi A. Recurrence of hidradenitis suppurativa after surgical management: A systematic review and meta-analysis. J Am Acad Dermatol. 2015 Nov;73(5 Suppl 1):S70-7.
31. Dalrymple JC, Monaghan JM. Treatment of hidradenitis suppurativa with the carbon dioxide laser. Br J Surg 1987;74:420.
32. Finley EM, Ratz JL. Treatment of hidradenitis suppurativa with carbon dioxide laser excision and second-intention healing. J Am Acad Dermatol 1996;34:465–9.
33. Mikkelsen PR, Dufour DN, Zarchi K, Jemec GB. Recurrence rate and patient satisfaction of CO2 laser evaporation of lesions in patients with hidradenitis suppurativa: a retrospective study. Dermatol Surg. 2015 Feb;41(2):255-60.
34. Dell'Antonia M, Anedda J, Tatti A, Falco A, Sanna S, Ferreli C, Atzori L. Non-surgical treatment of hidradenitis suppurativa: the role of cryotherapy. Front Med (Lausanne). 2023 Apr 18;10:1141691.
35. Molina-Leyva, A.; Salvador-Rodriguez, L.; Martinez-Lopez, A.; Cuenca-Barrales, C. Effectiveness, safety and tolerability of drainage and punch-trocar-assisted cryoinsufflation (cryopunch) in the treatment of inflammatory acute fluid collections in hidradenitis suppurativa patients. J. Eur. Acad. Dermatol. Venereol. 2019, 33, e221–e223.
36. Bong, J. L., Shalders, K., & Saihan, E. (2003). Treatment of persistent painful nodules of hidradenitis suppurativa with cryotherapy. Clinical and Experimental Dermatology, 28(3), 241–244.
37. Tang B, Huang Z, Yi Q, Zheng X. Complications of hidradenitis suppurativa after surgical management: A systematic review and meta-analysis. Int Wound J. 2023 Apr;20(4):1253-1261. doi: 10.1111/iwj.13945. Epub 2022 Oct 7. PMID: 36207796; PMCID: PMC10031239.
38. Li, Kaiyang & Jeremian, Richie & Bi, Wei Guang & Bouadi, Naila & Seigel, Kyle & Asgarpour, Jessica & Goldberg, Stephanie & Croitoru, David & Piguet, Vincent. (2024). Prognostic Factors in Hidradenitis Suppurativa Surgeries: A Scoping Review. JAAD Reviews. 1. 10.1016/j.jdrv.2024.06.005.
39. Janse I., Bieniek A., Horváth B., Matusiak Ł. Surgical procedures in hidradenitis suppurativa. Dermatol. Clin. 2016;34:97–109. doi: 10.1016/j.det.2015.08.007.
40. Bohn J., Svensson H. Surgical treatment of hidradenitis suppurativa. Scand. J. Plast. Reconstr. Surg. Hand Surg. 2001;35:305–309. doi: 10.1080/028443101750523230.
41. Lin C.-H., Chang K.-P., Huang S.-H. Deroofing: An effective method for treating chronic diffuse hidradenitis suppurativa. Dermatol. Surg. 2016;42:273–275. doi: 10.1097/DSS.0000000000000609.
42. Morgan W.P., Harding K.G., Hughes L.E. A comparison of skin grafting and healing by granulation, following axillary excision for hidradenitis suppurativa. Ann. R. Coll. Surg. Engl. 1983;65:235–236.
43. Morgan W.P., Harding K.G., Richardson G., Hughes L.E. The use of silastic foam dressing in the treatment of advanced hidradenitis suppurativa. Br. J. Surg. 1980;67:277–280. doi: 10.1002/bjs.1800670416.
44. Alabdulkareem M, Berkane Y, Le Bras E, Rousson E, Chrelias T, Beaufils T, Leclere FM, Watier E, Bertheuil N. Axillary Hidradenitis Suppurativa: A Comparison between Two Perforator Flap Reconstructive Approaches after Radical Surgical Management. Plast Reconstr Surg Glob Open. 2023 Oct 6;11(10):e5301. doi: 10.1097/GOX.0000000000005301. PMID: 37811354; PMCID: PMC10558224.
45. Wu Y, Ngaage LM, Ge S, Rada EM, Silverman RP, Rasko YM. Reconstruction for axillary hidradenitis suppurativa using one-stage local tissue rearrangement: A retrospective analysis of 53 cases. Int Wound J. 2020 Jun;17(3):701-707. doi: 10.1111/iwj.13319. Epub 2020 Feb 18. PMID: 32067416; PMCID: PMC7949289.
46. Steele AW, Miller NF, Wallace SJ, Hume KM, Sommers CA, Simmons CJ, Murphy RX Jr. Hidradenitis Suppurativa: A Comparison of Institutional Experience and the Tracking Operations and Outcomes for Plastic Surgeons Registry. Plast Reconstr Surg. 2022 May 1;149(5):1216-1224. doi: 10.1097/PRS.0000000000009024. Epub 2022 Mar 18. PMID: 35311802.
47. Nweze N, Parsikia A, Ahuja R, Joshi ART. Axillary Hidradenitis: Risk Factors for Recurrence after Surgical Excision in 214 Patients. Am Surg. 2018;84(3):422-427.
48. Walter AC, Meissner M, Kaufmann R, Valesky E, Pinter A. Hidradenitis Suppurativa After Radical Surgery-Long-Term Follow-up for Recurrences and Associated Factors. Dermatol Surg. 2018 Oct;44(10):1323-1331. doi: 10.1097/DSS.0000000000001668. PMID: 30204742.
49. Ravi S, Miles JA, Steele C, Christiansen MK, Sayed CJ. Patient Impressions and Outcomes After Clinic-Based Hidradenitis Suppurativa Surgery. JAMA Dermatol. 2022 Feb 1;158(2):132-141. doi: 10.1001/jamadermatol.2021.4741. PMID: 34985494; PMCID: PMC8733864.
50. Martorell A, Alfageme Roldán F, Vilarrasa Rull E, Ruiz-Villaverde R, Romaní De Gabriel J, García Martínez F, Vidal Sarro D, Velasco Pastor M, Ciudad Blanco C, Segura Palacios JM, Rodríguez Bandera AI, Pascual Ramírez JC, Sancho Sánchez C, Michelena De Gorosábel N, Wortsman X. Ultrasound as a diagnostic and management tool in hidradenitis suppurativa patients: a multicentre study. J Eur Acad Dermatol Venereol. 2019 Nov;33(11):2137-2142. doi: 10.1111/jdv.15710. Epub 2019 Jun 23. PMID: 31124183.
51. Issa, C.J., Hong, A.C., & Lio, P.A. (2024). Combined Biologic and Surgical Interventions for Hidradenitis Suppurativa: A Systematic Review. Dermatologic Therapy.
52. Sánchez-Díaz M, Díaz-Calvillo P, Rodríguez-Pozo JÁ, Arias-Santiago S, Molina-Leyva A. Effectiveness and Safety of Acitretin for the Treatment of Hidradenitis Suppurativa, Predictors of Clinical Response: A Cohort Study. Dermatology. 2023;239(1):52-59. doi: 10.1159/000526019. Epub 2022 Aug 23. PMID: 35998603.
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Copyright (c) 2026 Sahil Kapur, Kermanjot Sidhu, Mark Houdi, Lena Wuensch, Neha Iska, Bassem Chamma, Kritin Verma, Gabe Kleer, Craig G. Burkhart (Author)
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