Conventional scalpel
Wide excision involves the removal of affected tissue and an adjacent margin of healthy tissue. (Saunte & Jemec, 2017).
Excision can occur near the surface of the skin. In cases involving deeper tissue, excision may extend under the skin to include some of the fat layer. HS rarely extends through the fat layer to deeper structures so surgery does not typically involve large blood vessels or nerves.
Carbon dioxide (CO2) laser
CO2 laser excision is an ablative treatment that selectively targets and removes affected tissue while preserving surrounding healthy tissue (Omi & Numano, 2014). It is an effective alternative method to traditional excision or electrosurgery (Zouboulis, et al., 2019).
Wound closure techniques following excision
Healing times may be shortened if wound closure techniques are performed immediately following surgical procedures [7]. Although delayed primary closure, skin flaps, and skin grafts may shorten healing times, healing by secondary intention may have lower recurrence rates [7]. The extent of scarring varies between wound closure techniques. Following closure, wounds may also rupture at the site of the surgical incision. Given that further studies are still needed to provide appropriate recommendations [7], advantages and disadvantages of each should be considered in order to determine optimal techniques for each patient.
Secondary intention
Healing by secondary intention involves letting the wound heal from the bottom up and side to side without suture closure, resulting in a longer but more comfortable recovery period (Vellaichamy, Braunberger, Nahhas, & Hamzavi, 2018).
Delayed primary closure
Delayed closure involves leaving wounds open initially, but then performing wound closure at a later time, typically days to a few weeks after the initial surgery (Chen, Gerstle, Verma, Treiser, Kimball, & Orgill, 2014). Although it decreases the risk of infection, it requires nursing care, causes significant discomfort, and includes the need for a second procedure typically requiring general anesthesia (Chen, Gerstle, Verma, Treiser, Kimball, & Orgill, 2014).
Skin flaps
Flaps provide thicker coverage but can be bulky and require second procedures for thinning in order to achieve a natural skin contour (Alikhan, et al., 2019). This typically requires more extensive surgery, and scarring may extend beyond the typical “hidden” areas of HS so that skin can be moved into position to cover the wounds.
Skin grafts
“Recycled” skin grafts are sections of skin that have been removed and preserved prior to being reapplied (Orgill, 2019). Skin grafts are most often taken from the thighs or buttocks in areas of uninvolved skin. This technique is similar to treating large burns (Alikhan, et al., 2019).
Skin substitutes
Biosynthetic skin substitutes are dressings used in the treatment of burn wounds (Melkun & Few, 2005). They may provide decreased healing times, less pain, and shorter hospitalizations in pediatric patients, though controlled studies comparing skin substitutes to other types of healing are lacking (Melkun & Few, 2005).
Unroofing/deroofing involves removing the “roof” of an abscess or sinus tract (tunnel), leaving tissue to heal at the bottom by secondary healing (van Straalen, Schneider-Burrus, & Prens, 2018).
The procedure can be local or extensive, which involves individual lesions or all lesions in an affected region, respectively (Orgill, 2019).
Please refer to the light, laser & energy sources section.
STEEP is a tissue-sparing technique whereby affected tissue is successively removed by electrosurgery and wounds are left to heal by secondary intention, resulting in low recurrence rates, short recovery times, and fewer complications (Blok, Spoo, Leeman, Jonkman, & Horváth, 2015). It is effective for those with Hurley stage II or III (Blok, Spoo, Leeman, Jonkman, & Horváth, 2015; Lexicomp, 2019), or chronic lesions. Evidence is lacking to recommend its use to treat isolated acute lesions (Alikhan, et al., 2019).
Cyrosurgery is a method that uses liquid nitrogen to freeze and destroy lesions or sinus tracts (Hidradenitis Suppurativa Foundation Inc.). Given that evidence is lacking to recommend its use to treat isolated acute lesions, further studies are still needed to understand how cryosurgery can best be used to treat HS.
Following anesthesia, the affected area is cut and drained. An absorptive packing material may be placed on the resulting wound (Vellaichamy, Braunberger, Nahhas, & Hamzavi, 2018).
A combination of medical treatments, such as biologics, and surgical treatments may be used for those who have failed to respond to other treatments (DeFazio, et al., 2016), as medications pose a lower risk for surgical complications compared to uncontrolled cases of HS. Although there are no contraindications, evidence is limited (Alikhan, et al., 2019).
Conventional scalpel
Those with Hurley stage II or III (Vellaichamy, Braunberger, Nahhas, & Hamzavi, 2018) or chronic lesions.
Patients at any Hurley stage (Orgill, 2019; van der Zee, Prens, & Boer, 2010). It can be considered in those with small acute lesions, although it is likely best-suited to treat recurrent nodules or sinuses (Alikhan, et al., 2019).
Those who want rapid pain relief for tense and fluctuant abscesses after failing to respond to other treatments (Vellaichamy, Braunberger, Nahhas, & Hamzavi, 2018).
Conventional scalpel
It is typically not necessary for patients with Hurley stage I or new lesions that have been present for less than 1-2 months.
No absolute contraindications.
It should not be used as the sole treatment since inadequate elimination of tissue and sinuses frequently leads to recurrences (Hidradenitis Suppurativa Foundation Inc.).
Those who received multiple incision and drainage procedures should consider other surgical treatments (Vellaichamy, Braunberger, Nahhas, & Hamzavi, 2018).
Patients with a bleeding disorder or allergies to lidocaine, epinephrine, or latex should speak to their health care provider beforehand (Downey & Becker, 2019).
Conventional scalpel
Level of Evidence: Level II
Strength of recommendation: “B” rating
Lower recurrence rates were achieved following wide excision compared to other surgical procedures, and following the use of skin flaps or grafts after wide excision compared to other wound closure techniques (Mehdizadeh, et al., 2015).
Carbon dioxide (CO2) laser
Level of Evidence: Level II
Strength of recommendation: “C” rating
7 HS patients obtained satisfactory results and experienced minimal complications following CO2 laser excision and subsequent healing by secondary intention (Finley & Ratz, 1996).
Recurrence rates seem low but healing times may be prolonged following CO2 laser excision with healing by secondary intention (Alikhan, et al., 2019).
Wound closure techniques following excision
Secondary intention
Level of Evidence: Level II
Strength of recommendation: “C” rating
Complete wound healing was achieved 8-16 weeks following wide excision and healing by secondary intention in 17 HS patients, some of which developed recurrence or flares, or experienced limited ranges of motion (Humphries, Kueberuwa, Beederman, & Gottlieb, 2016).
Delayed primary closure
Level of Evidence: Level II
Strength of recommendation: “C” rating
Reasonable outcomes were achieved when delayed primary closure was performed following internal vacuum-assisted closure therapy in 27 HS patients (Chen, Gerstle, Verma, Treiser, Kimball, & Orgill, 2014).
Skin flaps
Level of Evidence: Level II
Strength of recommendation: “C” rating
Following the use of skin grafts and flaps on 29 and 14 HS affected areas, respectively, no recurrences or serious complications were observed. In comparison, recurrence occurred in >50% of the 100 HS affected areas treated by primary closure, though there were likely differences in the extent of surgery performed in these groups (Mandal & Watson, 2005).
Skin grafts
Level of Evidence: Level II
Strength of recommendation: “C” rating
Following wide excision, 6 weeks was the average time for complete healing in the skin graft group compared to 10 weeks in the secondary intention group. Partial graft loss and recurrence was 37.5% and 1.8%, respectively (Bocchini, Habr-Gama, Kiss, Imperiale, & Araujo, 2003).
Skin substitutes
Level of Evidence: Level II
Strength of recommendation: “C” rating
Treatment consisting of wide excision with a biosynthetic skin substitute in 4 HS patients was successful, with an average complete healing time of 3 months (Melkun & Few, 2005).
Level of Evidence: Level II
Strength of recommendation: “B” rating
After a follow-up period of about 34 months, recurrence was not observed in the majority of the 88 deroofed lesions. 90% of the 44 Hurley stage I or II patients stated they would recommend it to others (van der Zee, Prens, & Boer, 2010).
It is preferred to drainage (Alikhan, et al., 2019).
Level of Evidence: Level II
Strength of recommendation: “C” rating
The majority of Hurley stage I or II patients, as well as lesions, were cured within 15 to 21 days following electrosurgery. Infection was noted in a few Hurley stage II patients (Aksakal & Adişen, 2008).
Level of Evidence: Level III
Strength of recommendation: “C” rating
Among 10 HS patients with persistent and painful nodules treated with cryosurgery, the majority improved, although pain and post-procedural complications were reported (Bong, Shalders, & Saihan, 2003).
Level of Evidence: Level II
Strength of recommendation: “C” rating
In a study involving 590 HS patients, recurrence risk was higher among those who underwent incision and drainage compared to excision, and unroofing (Kohorst, et al., 2016).
Level of Evidence: Level II
Strength of recommendation: “C” rating
Improvement, and thus a reduced need for surgery, were observed in a greater number of long-term HS patients who randomly received adalimumab after 12 weeks compared to placebo (Zouboulis, et al., 2016).
Conventional scalpel
Serious: Infection, though this is uncommon (Orgill, 2019).
Other: Bleeding, new disease at the edge of the excision site (Orgill, 2019), poor wound healing, pain, scarring, reduced mobility (Saunte & Jemec, 2017).
Pregnancy risk according to the U.S Food and Drug Administration (FDA):
Serious: None.
Other: Bleeding, infection (Zouboulis C. C., et al., 2015).
Pregnancy risk according to the FDA:
Although uncommon, side effects typically result from inadequate or excessive drainage (Downey & Becker, 2019).
Conventional scalpel
Wide excision is typically performed in a hospital under a general anesthetic (Hidradenitis Suppurativa Foundation Inc.). Although usually unnecessary, hospitalization for up to a week is considered for complicated wounds.
Patients may experience prolonged recovery periods given that wide excision leads to larger wounds than more localized procedures (Vellaichamy, Braunberger, Nahhas, & Hamzavi, 2018).
Open wounds may take several weeks or months to fully heal. Discomfort may limit daily activities for 1-4 weeks (or infrequently longer) depending on the level of pain control, wound size, and type of activity required.
Local or general anesthesia can be used depending on the size of the affected area(s) (van Hattem, Spoo, Horváth, Jonkman, & Leeman, 2012).
Dressings, which are changed daily, are used for care following surgery (van Hattem, Spoo, Horváth, Jonkman, & Leeman, 2012).
Recovery is typically more rapid (3-6 weeks) than with similarly sized wide or local excisional procedures. Avoidance of daily activities may be required for up to a few weeks after the procedure, but this period can be shortened for less severe cases.
Although it relieves pain and pressure, recurrence is almost inevitable for recurrent lesions (van Straalen, Schneider-Burrus, & Prens, 2018).
Dry gauze should be used to cover open wounds until fully healed (Downey & Becker, 2019).
There can be discomfort with dressing changes if the wound is packed. The benefit of packing is unclear.