In what cases would you recommend surgery, based on Hurley stage, condition severity, and affected site?
Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that often presents with painful, recurrent lumps, abscesses, and scarring, typically in areas where skin rubs together, such as the underarms, groin, buttocks, and under the breasts. Obesity is a well-established risk factor for HS, and the majority of patients with HS are overweight or obese.
The Hurley staging system is commonly used to classify the severity of HS and to guide treatment decisions.
Hurley Stage I: mild disease. Patients experience isolated abscesses or lumps that do not connect under the skin. The lumps may appear as single, recurrent boils, often misdiagnosed as simple infections or cysts.
Hurley Stage II: moderate disease. Patients experience more widespread and persistent HS. The condition involves the formation of multiple abscesses in one or more areas of the body.
Hurley Stage III: severe disease. It’s marked by extensive scar tissue and chronic infection, covering a large area of skin. The tracts are deep, and there may be multiple sinuses draining purulent (pus-like) fluid.
What criteria require the following surgeries, and how do they work/help?
Surgery is considered for HS when medical treatments such as antibiotics, biologics, and lifestyle modifications, such as weight loss, do not adequately control symptoms, especially in moderate to severe cases (Hurley stages II and III). The indication for surgery depends on the extent, severity, and chronicity of the disease, as well as the impact on the patient’s quality of life.
Incision and drainage (I&D) is used for acute abscesses to relieve pain and reduce infection, though it’s often temporary, and abscesses may recur.
Local excision targets specific lesions or sinuses for removal, usually effective in Hurley Stage II. It can reduce recurrence in specific areas but may not prevent new lesions elsewhere.
Wide excision involves the complete removal of affected skin and subcutaneous tissue, typically in Hurley Stage III. The excised area may need skin grafting for closure, but this approach is often the most effective for long-term relief.
Laser surgery, such as carbon dioxide laser excision and hair removal, can be effective in early stages by reducing hair follicles, which may reduce inflammation and lesion formation.
Deroofing is a surgical procedure that treats hidradenitis suppurativa (HS) by removing the “roof” of an abscess, cyst, or sinus tract. The procedure is performed under local anesthetic and involves using a probe to identify the full extent of the lesion, and removing the diseased tissue that causes the abscess or tunnel while leaving the mostly dermal wound base to heal. The goal of deroofing is to replace painful or chronically draining areas with a scar that is no longer painful or drains pus.
What kind of post-op recovery should people expect (pain, time, etc.) and how do recovery expectations change based on surgery type?
Post-operative recovery for HS varies depending on the type and extent of surgery performed. Recovery expectations can include variations in pain levels, healing time, wound care needs, and the possibility of complications.
1. Incision and drainage (I&D). Patients can often resume normal activities within a few days, though some soreness may persist for a week. Regular dressing changes are essential, and patients might be instructed to cleanse the area daily. The wound may remain open and heal from the inside out over 1–2 weeks.
2. Limited excision. Mild to moderate pain post-procedure, typically manageable with over-the-counter pain relievers. Pain may last 1–2 weeks, depending on wound size. Recovery typically takes around 2–4 weeks, during which patients should limit strenuous activities and follow their provider’s wound care instructions. Healing is usually complete within a month, though some scarring can occur.
3. Wide excision. Pain can be significant due to the extensive nature of the surgery. Prescription pain medication is often necessary, and pain may persist for several weeks. Recovery is generally longer, taking 6–12 weeks or more. Intensive wound care is essential, involving daily dressing changes and hygiene to prevent infection. Complete healing may take several months, and scarring is common. Rehabilitation may be required to regain function if excision affected mobility.
4. Laser surgery (carbon dioxide laser excision). Pain is typically mild to moderate, with a quicker recovery than traditional excision. Over-the-counter pain relief is often adequate. Healing usually takes around 1–2 weeks, with some restrictions on physical activities. Minimal wound care may be needed. Scarring may be minimal, though multiple treatments may be needed for ongoing HS management.
HS is often a long-term condition, and surgery can be challenging both physically and emotionally. Support groups, counseling, or therapy may help with adjustment during recovery and in coping with the chronic nature of HS.