When Hidradenitis Needs the Operating Room

Why Some Hidradenitis Needs Surgery at All

Hidradenitis suppurativa forms tunnels, chronic interconnected channels under the skin lined with inflamed tissue, that generally do not close on their own or in response to medication once they've fully formed 1Ref 1Sabat R, Jemec GBE, Matusiak Ł, et al. (2020).Hidradenitis suppurativa.Hidradenitis suppurativa forms chronic tunnels lined with inflamed tissue that generally do not resolve with medication once formed; background for why surgery targets existing tissue while medical treatment targets ongoing inflammation.. Antibiotics, hormonal therapy, and biologic drugs can quiet the inflammation driving new lesions, but none of them reliably dissolves an established tunnel; that's a structural problem, not just an inflammatory one, and it's a meaningful part of why surgery enters the treatment ladder for some people with HS 2Ref 2Alikhan A, Sayed C, Alavi A, et al. (2019).North American clinical management guidelines for hidradenitis suppurativa: Part I: Diagnosis, evaluation, and the use of complementary and procedural management.North American HS guideline covering severity staging and procedural/surgical management options, including deroofing and excision, for tunnels and disease not controlled by medical therapy alone..

Surgery in HS is aimed at tunnels and scarred tissue that already exist. It doesn't replace medical treatment for the inflammation still driving new lesions elsewhere on the body.

Deroofing: The Smaller, More Common Procedure

Deroofing, also called unroofing, involves opening the top of an abscess or tunnel, removing the roof of inflamed tissue, and leaving the wound to heal open from the base up rather than stitching it closed 2Ref 2Alikhan A, Sayed C, Alavi A, et al. (2019).North American clinical management guidelines for hidradenitis suppurativa: Part I: Diagnosis, evaluation, and the use of complementary and procedural management.North American HS guideline covering severity staging and procedural/surgical management options, including deroofing and excision, for tunnels and disease not controlled by medical therapy alone.. It's typically done under local anesthesia in an outpatient setting, targets a single lesion or a short connected tunnel, and preserves more surrounding tissue than a wider excision would.

Because the wound heals by what's called secondary intention, filling in with new tissue from the base up rather than being sewn shut, recovery involves ongoing wound care rather than a single healing point, and the resulting scar pattern differs from a stitched incision. Deroofing is generally reserved for tunnels that are limited in extent rather than widespread, interconnected disease across a whole region.

Because it's less invasive than a wider excision, deroofing can sometimes be repeated if a new, separate tunnel forms near a previously treated one, which is not unusual in a disease that tends to recur close to where it's already been active. It's also a reasonable option for someone who isn't a candidate for a longer procedure under general anesthesia, since it's typically well tolerated under local anesthesia alone.

Wide Excision: When the Disease Has Outgrown Deroofing

Wide local excision removes an entire affected area of skin down through the tunnels and scarred tissue, rather than just opening the roof of one lesion, and it's the option surgeons reach for when disease in a region is extensive, deeply interconnected, or has already outgrown a more limited procedure 2Ref 2Alikhan A, Sayed C, Alavi A, et al. (2019).North American clinical management guidelines for hidradenitis suppurativa: Part I: Diagnosis, evaluation, and the use of complementary and procedural management.North American HS guideline covering severity staging and procedural/surgical management options, including deroofing and excision, for tunnels and disease not controlled by medical therapy alone.. The wound that results is larger, and how it's closed, left open, closed directly, covered with a skin graft, or reconstructed with a flap, depends on how much tissue was removed and where on the body it sits.

Recovery from wide excision generally runs longer than deroofing, and the decision to go this route weighs disease extent against the anatomic complexity of the area involved, since some sites, the armpit or groin among them, tolerate wound healing and grafting differently than others.

Larger excisions are more often done under general or regional anesthesia, sometimes in an operating room rather than a procedure suite, and may involve a drain placed temporarily to manage fluid while the wound heals. A skin graft takes tissue from elsewhere on the body to cover the wound directly; a flap moves nearby tissue, with its own blood supply intact, to cover it instead. Which one a surgeon chooses depends on the size of the defect and how well the surrounding skin can be mobilized.

How Staging Guides the Choice

Hidradenitis suppurativa is staged largely by how many lesions are present, whether tunnels have formed, and how interconnected the disease is across a region, a framework that also tells a surgeon whether deroofing a single tunnel will likely be enough or whether the surrounding tissue is too extensively involved for anything short of wide excision 2Ref 2Alikhan A, Sayed C, Alavi A, et al. (2019).North American clinical management guidelines for hidradenitis suppurativa: Part I: Diagnosis, evaluation, and the use of complementary and procedural management.North American HS guideline covering severity staging and procedural/surgical management options, including deroofing and excision, for tunnels and disease not controlled by medical therapy alone.. This staging sits inside the same hidradenitis suppurativa treatment by stage ladder that clinicians already use to sequence topical, oral, and biologic therapy, and surgery slots into that framework rather than existing apart from it.

Surgery Alongside Medical Treatment, Not Instead of It

Surgery addresses tissue that has already formed tunnels; it does nothing about the immune activity still driving new lesions to form elsewhere on the body 1Ref 1Sabat R, Jemec GBE, Matusiak Ł, et al. (2020).Hidradenitis suppurativa.Hidradenitis suppurativa forms chronic tunnels lined with inflamed tissue that generally do not resolve with medication once formed; background for why surgery targets existing tissue while medical treatment targets ongoing inflammation.. A biologic such as adalimumab for hs reduces how many new inflamed nodules and abscesses appear, which is a different job than closing an existing tunnel, since the trials behind that approval measured a drop in active, inflamed lesions rather than resolution of tunnels that had already formed 3Ref 3Kimball AB, Okun MM, Williams DA, et al. (2016).Two Phase 3 Trials of Adalimumab for Hidradenitis Suppurativa.The PIONEER trials measured a reduction in active, inflamed lesions with adalimumab, not resolution of existing tunnels; used to contrast what a biologic addresses versus what surgery addresses..

For that reason, many people move through both: medical therapy to control ongoing inflammation, and a procedure to address tunnels or scarring that medication alone won't touch. Timing matters too, since operating on actively inflamed skin can carry higher complication risk than operating on quieter tissue, and that's part of what a surgeon and dermatologist weigh together before scheduling.

Recovery, Recurrence, and What Surgery Doesn't Fix

Wound care after either procedure is ongoing rather than a one-time event, particularly after deroofing, where the open wound is dressed and monitored as it fills in over time 2Ref 2Alikhan A, Sayed C, Alavi A, et al. (2019).North American clinical management guidelines for hidradenitis suppurativa: Part I: Diagnosis, evaluation, and the use of complementary and procedural management.North American HS guideline covering severity staging and procedural/surgical management options, including deroofing and excision, for tunnels and disease not controlled by medical therapy alone.. Recurrence is possible in the treated area, and it's also common for HS to remain active in other regions of the body the surgery didn't touch, which is why surgery is generally framed as treating one affected area rather than curing the disease overall.

Follow-up after either procedure typically continues past the point the wound has closed, since a surgeon and dermatologist are both watching for two different things: whether the surgical site is healing well, and whether the underlying disease is staying controlled on whatever medical treatment is running alongside it. A surgeon who regularly treats HS, rather than one who has done only a handful of cases, is often better positioned to judge margins around a tunnel that isn't always obvious from the skin surface, since tunnels can extend further under intact-looking skin than they appear to from outside.

What to Ask Before Scheduling a Procedure

Before scheduling either deroofing or a wide excision, it's worth asking directly how the surgeon decided which procedure fits the case, what the plan is if disease is found more extensive than expected once the procedure has started, and what the follow-up schedule looks like for wound care afterward. Those answers tend to differ meaningfully between a surgeon who treats HS often and one who doesn't.

It's also worth confirming who is managing the medical side of treatment during the surgical recovery period, since stopping or pausing a biologic or other medication around the time of a procedure is a decision that belongs to the dermatologist and surgeon together, not something to work out after the fact.