Surgical Management of HS

Hidradenitis suppurative (HS) is a chronically progressive inflammatory disorder that causes painful abscesses and tunnels in areas rich in sweat glands. For individuals that have localized, but severe symptoms, surgical treatment is a widely accepted management strategy.

The decision to pursue surgery is multifactorial. Surgical planning includes the extent and severity of HS, the recurrence pattern of HS, the regions that are affected, and the ease of operability at those sites.1 The Hurley Staging System is a grading scale used to determine the extent of HS and inform management decisions.

Hurley Staging System

Stage I: Single/Multiple abscess formation without scarring.

Stage II: Recurrent abscesses with scarring and widespread lesions.

Stage III: Diffuse abscesses with multiple interconnected tracts.

stages

Not all patients move from Stage I to II and then III, but once HS progresses to a more advanced stage, it can be difficult to reverse some of the changes that have occurred in the skin, such as the formation of scars and sinus tracts.

Surgical management should be performed when the active inflammatory processes of HS are at a minimum.3 Patients tend to see a range of subspecialty surgeons such as general, plastic, and potentially gynecological surgeons throughout their pre- and post-operative care.

Surgical Methods for HS Management

Incision and Drainage

Primarily initiated to relieve symptoms of acutely severe abscesses. For this procedure, local anesthetic is provided to the affected area, and an incision is made to drain the abscess. Though this method provides immediate pain relief, the rate of recurrence is high.

Deroofing Surgery

This is a minimally invasive procedure, that is commonly used in Hurley I and II subtypes of HS lesions. Deroofing involves removing the “roof” of the abscess or sinus tract of HS lesions. This is preferred over incision and drainage as this encourages proper healing through secondary intention, while providing minimal scarring for better cosmetic results.

Wide Level Excision/Skin Flaps & Grafts

In severe HS lesions, wide level excision is often used for curative measures of advanced HS. Excision involves the removal of all tissue at the affected region, including skin, subcutaneous fat, nodules, and sinuses.1 There is much debate as to the best methods for healing post-operatively. Surgical wounds can be healed through primary closure, secondary intention or with the use of skin flaps and grafts.1 There has been some evidence showing that the rate of recurrence is lower in patients who received a skin flap for healing after wide level excision.1 This is believed to be due to the inclusion of an additional blood supply from the skin flaps, which allow for better perfusion of the area during recovery. Overall however, secondary intention has a lower risk of recurrence especially compared to primary closure.4

 References

  1. Chawla S, Toale C, Morris M, Tobin AM, Kavanagh D. Surgical Management of Hidradenitis Suppurativa: A Narrative Review. J Clin Aesthet Dermatol. 2022;15(1):35-41.
  2. Shukla R, Karagaiah P, Patil A, et al. Surgical Treatment in Hidradenitis Suppurativa. J Clin Med. 2022;11(9):2311. Published 2022 Apr 21. doi:10.3390/jcm11092311
  3. Hidradenitis Suppurativa Foundation. Surgical Treatment in Hidradenitis Suppurativa: Options, Procedures, and Outcomes. Hidradenitis Suppurativa Foundation. Accessed December 6th , 2024. https://hsfoundation.ca/surgical-treatment-in-hidradenitis-suppurativa/
  4. Pena-Robichaux V, Goldberg S. Procedural treatments for hidradenitis suppurativa. J Am Acad Dermatol. 2024;91(6):S46-S51. doi:10.1016/j.jaad.2024.08.072

Images

Health Union. Physical Examinations and the Hurley Staging of Hidradenitis Suppurativa. HSDisease.com. Published December 2020. Accessed December 6th, 2024. https://hsdisease.com/physical-exam

HS Ireland. Surgical Techniques for HS 2: Mini-Unroofing and Deroofing. HS Ireland. Published May 30, 2021. Accessed December 28, 2024. https://hsireland.ie/surgical-techniques-for-hs-2-mini-unroofing-and-deroofing/

Submitted by: Ernest Chan

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