Are You a Candidate for Hidradenitis Suppurativa Surgery?

Medically Reviewed By William C. Lloyd III, MD, FACS

If you have been diagnosed with acne inversa, also known as hidradenitis suppurativa, you’ve likely been in search of relief from this chronic, sometimes painful and debilitating disease. In moderate-to-severe acne inversa, antibiotics and the injected biologic adalimumab have provided clinical benefit for some patients. Though no definitive cure has been found, surgery has also been shown to be an effective treatment for many individuals. Using what is known as a wide excision, the entire diseased area, as well as a border of healthy tissue surrounding it, is surgically removed.  But how do you know if you are a candidate for this procedure?

To answer this question, it’s important to address both how this disease physically manifests itself and how it affects your quality of life.

How severe is your case?

Hidradenitis suppurativa presents as inflamed pimple-like bumps or boils under the skin. It commonly occurs in areas that are prone to sweat or with skin-to-skin contact, such as the underarm, groin, and buttocks. These inflamed areas can become painful and may drain pus that often has an unpleasant smell. As the disease progresses, these may form deep abscesses and a connection of tunnel-like tracts, called sinus tracts, beneath the skin. Additionally, thick scars can develop, resulting in difficulty moving the affected area.

The severity of hidradenitis suppurativa can range from person to person. Doctors will often use a system called the Hurley Criteria to classify patients. 

  • Hurley’s Stage I: There may be single or multiple affected areas that are widely separated, without scarring or sinus tract formation.

  • Hurley’s Stage II: Recurrent affected areas are seen but are still widely separated. Sinus tracts and scars are formed.

  • Hurley’s Stage III: Large areas are affected with multiple sinus tracts and scars.

Mild cases, such as those in Stage I, will generally be managed medically. However, patients with recurrent and more severe disease in Stage II and III who have failed to respond to medical treatment may be considered candidates for surgery to remove the abscesses and the sinus tracts.

Yet once the disease becomes too widespread, as in advanced Stage III cases, surgery may be more difficult. For this reason, when surgery is an appropriate treatment, it is recommended to act early, rather than delay the procedure and risk too much tissue involvement.

Is your quality of life impacted by your disease?

Living with hidradenitis suppurativa can be challenging. Patients not only experience pain and discomfort but may also have psychological difficulties. Worries about appearance, fear of body odor, and troubles with sexuality can occur, leading to depression and withdrawal.  Patients who have a significant decrease in their quality of life can benefit from proper counseling and support, as well as early surgical intervention for the disease.

Are you aware of the risk of recurrence?

All surgical patients must understand that although hidradenitis suppurativa shouldn’t return to the area that was removed, it may reappear on other parts of the body. Risk factors such as obesity, smoking, chronic skin infection, and stress have also been linked to higher likelihood of recurrence. Those who are willing to make some lifestyle changes may be more likely to have a positive outcome after surgery.

How is wide surgical excision performed?

Before surgery can occur, any infection or inflammation must first be treated, often through the use of antibiotics. During the procedure, the area affected by hidradenitis suppurativa is excised, or removed, along with a margin of unaffected tissue surrounding it. In some cases, the wound may be closed with stitches. However, since the area removed is often large and deep, it may require using healthy skin from other areas of the body to help cover the wound.

Are there other less invasive surgical options?

Although they are less likely to offer long-term relief, a few other surgical procedures can be considered:

  • Incision and drainage: A cut is made into the abscess, allowing the pus to drain out. This may improve pain temporarily, but lesions are likely to come back.

  • Unroofing: The skin and tissue covering the sinus tracts are removed, and the wound is left to heal. This is often helps reduce inflammation and is more successful than incision and drainage.

  • Laser surgery: Carbon dioxide laser surgery is a newer treatment and is showing some success in clearing affected areas.

If you believe you’re a good candidate for surgery, discuss this with your doctor. Remember every case is different, and many patients require multiple forms of treatment in order to achieve their desired results. Be open with your doctor about your experience and your concerns, so that together you can find the answers you need.

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  1. Hidradenitis Suppurativa: Current and Future Treatments: Severity Assessment of HS. Medscape.
  2. Rambhatla PV, Lim HW, Hamzavi I. A Systematic Review of Treatments for Hidradenitis Suppurativa. Archives of Dermatology. 2012;148(4):439-446. doi:10.1001/archdermatol.2011.1950
  3. Shah, N. Hidradenitis Suppurativa: A Treatment Challenge. American Family Physician. 2005 Oct 15;72(8):1547-52.
Medical Reviewer: William C. Lloyd III, MD, FACS
Last Review Date: 2022 Dec 4
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