Surgical Management of Hidradenitis Suppurativa: Deroofing, Excision, and Wound Healing Tips

The speaker emphasizes that surgery is an important and increasingly standard part of hidradenitis suppurativa (HS) care, especially for recurrent or persistent lesions that do not fully respond to medication. He explains that not every patient needs a large excision; many benefit from focused procedures such as deroofing of tunnels and limited excision of resistant areas. He describes how to identify surgical targets by asking patients where flares recur and by looking for long-standing lesions, tunneling, drainage points, epithelialized shiny areas, and prominent comedones at scar borders. Deroofing is presented as a key technique because it preserves more dermis, heals faster, and maintains better pliability than deep excision. He outlines practical operative tips, including using a blunt probe to map tunnels, working in a superficial dermal or subcutaneous plane, using forceps and scissors for most of the dissection, and controlling bleeding with options such as cautery or topical agents. He also discusses anesthesia and office-based logistics, including staged procedures, pre-procedure diazepam, and generous local anesthetic volume. For wound healing, he explains the normal progression from inflammatory phase with yellow slough, to granulation, to epithelialization and contraction over the first several weeks, noting that persistent wounds beyond 6 to 8 weeks may need evaluation for hypergranulation or ongoing inflammation. He recommends topical triamcinolone or clobetasol as first-line treatment for hypergranulation. He also reassures that surgery can be combined safely with biologics like adalimumab, and that smoking or obesity do not appear to dramatically worsen healing in HS surgical cohorts. Overall, he stresses that surgery often yields high satisfaction, meaningful symptom relief, and may be especially valuable when a single stubborn area keeps recurring.