Surgery & Procedures
There are many options for the treatment and management of HS, most of which include some type of surgery. Below are the most common types of surgical procedures used for HS.
There is no cure for HS, it is a very personal disease and electing to have surgery is also a personal decision. As with most things in life, there are no guarantees, but you don’t know if it works for you unless you try.
For the best chance of success in treating your HS, start by finding a qualified plastic surgeon or general surgeon experienced with HS who has preferably worked with several HS patients. Don’t be afraid to ask the surgeon about their experiences with HS patients. No surgeon can perform a surgery without your written consent. For example, if you don’t want a graft and your surgeon recommends it, tell them why you are electing not to have a specific procedure done. You are not obligated to have surgery with a doctor you don’t feel comfortable with or confident in. It is imperative that you advocate for yourself during this process.
As a patient, surgery success has many measurements. You may hear people complain about surgery “failing”; please keep in mind there is usually a reason for failure that could include any of the following, all of which we see often:
Went to the wrong surgeon or a surgeon inexperienced with HS
Surgeon may not have removed all of the disease, tunneling and scar tissue
Surgeon may not have gone deep enough or cut wide enough
Surgeon may close the site and may trap in the disease, which does not give it time to completely drain
If you're considering surgery, be mindful of negative stories. We’ve all heard people complain about surgery only to find out they had 10 years of relief (which for an HS patient is nothing to complain about).
Incision and Drainage (I & D) / Lancing:
This is an outpatient procedure and is not necessarily considered HS surgery. It is a temporary drainage and should be avoided as maintenance for HS. Please attempt to arrange an I & D with your dermatologist as opposed to going to the ER or Urgent Care as they are not typically qualified to perform this procedure for HS. It should not be used as a repetitive long-term treatment for HS and should only be done when other measures have failed and/or when cellulitis or infection is present and your physician feels it's safe enough.
After this procedure the patient is typically instructed to watch for signs of cellulitis or recollection of pus. The patient or family is usually trained to change packing or arrange for the patient’s packing to be changed as necessary.
I & D of a perianal abscess may result in a chronic anal fistula and may require a fistulectomy by a surgeon; I & Ds should be avoided in this area.
Please read more on lancing here.
Mini De-Roofing or Limited De-Roofing (not an I & D):
This procedure may be used to remove a single inflamed nodule/abscess or with some scaring. A biopsy punch of appropriate diameter is centered over the involved area and a twisting incision removes the central damaged material. This is then debrided with digital pressure, grattage (removal of granulations to stimulate the healing process) with gauze wrapped around a cotton applicator.
This is usually done for people with Stage I and II (mild to moderate). De-roofing is a minimally invasive procedure where the ‘ROOF’ of an abscess/sinus tract is surgically removed and a cross-shaped incision is made over the abscess to open it. The pus and dead tissue are removed and then the cavity is filled with antiseptic-soaked packs. This is different from the wide excision surgeries and less invasive.
Photos below are prior to deroofing of 3 abscesses. The Dermatologist started with the bottom abscess which was recurring and discovered that there was tunneling to the other 2 abscesses, so she removed all 3.
Staged CO2 Laser Marsupialization Surgery (CO2 laser surgery):
CO2 laser surgery can be performed under local or general anesthesia. Typical healing is by 2nd intent (left open to heal from the inside out).
There are various different lasers used during the CO2 treatment procedure, all having different functions and targeting various different aspects without damaging the skin. The CO2 vaporizes the flesh.
Learn more about the CO2 laser procedure in an interview with Dr. Barry Resnik here.
This laser targets the hair follicle directly, destroying the pilosebaceous unit and the follicular inflammation. Several sessions may be needed based on your personal HS. This procedure is best used for stage II to III and may help with inflammation. Some laser and light-based options are being used as systemic therapies. Nd:YAG laser research can be found here. Additional research on laser treatment can be found here.
Tissue-Sparing or Skin-Tissue-sparing Excision with Electrosurgical Peeling (STEEP):
This may be an option for people stage II to III. It combines skin-tissue-sparing removal (excision) of damaged tissue with electrosurgical (electrosurgery refers to the cutting and coagulation of tissue using high-frequency electrical current) peeling. STEEP research can be found here.
Wide Excision Surgery with 2nd Intent (left open to heal from the inside out):
A qualified surgeon (typically a plastic surgeon) removes the entire affected and diseased area, which includes all of the tunneling and scar tissue as deep as the disease, tunneling and scarring burrow. There is a low risk of infection during healing and this procedure has the lowest rate of recurrence.
Many HS patients have had great success and years of relief with wide excision surgery.
Wide Excision with Primary Closure:
Closure is not recommended as the disease can get trapped underneath and behind the incision. This typically causes abscesses to start forming immediately after surgery at the surgery site. The stitches and/or staples typically open or tear open right after surgery. There is also a higher risk for infection with this procedure and there is a higher recurrence rate with closure based on experience from the advocacy aspect as well as cited in some research.
Wide Excision Surgery with Skin Graft or Flap:
Note: It does not matter how deep or how large the surgery area is, skin grafts or flaps are NOT needed unless medically necessary, please discuss with your surgeon.
There are very specific medical circumstances (sometimes in the anal area or vaginal area) where a graft or flap may be needed and are usually only for cosmetic reasons. Grafts or flaps are not ideal for HS patients. The drawbacks to this surgery include that the skin grafts or flap do not take, there is additional unnecessary surgery, longer recovery at donor site, higher high risk for secondary complications and a higher rate for recurrence as opposed to other methods.
HS is not considered a gland disease. Gland removal is not necessary and not needed unless tunneling has become severe enough that it is affecting your glands making it necessary (unusual). There is no guarantee it will help your HS or boost your chances of success by getting your glands removed.
Watch the interview with Dr. Stephanie Goldberg on surgical procedures for HS here.
Photos of procedures and healing can be found here.
Medical and Surgical Treatment of Hidradenitis Suppurativa: A Review
Content in this article is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay seeking treatment because of something you have read on this website.
Written by Denise Panter-Fixsen
Edited by Brindley Kons