Management Strategies in HS

Surgical management plays a crucial role in hidradenitis suppurativa (HS) treatment, particularly for patients with persistent draining tunnels (sinus tracts) that respond poorly to medical therapy alone. The surgical approach targets the distinct inflammatory environment within sinus tracts, which differs from other HS lesions and contains a mixed inflammatory cell population that medical treatments struggle to eliminate completely. For single draining tunnels, deroofing procedures work effectively, while patients with multiple interconnected tunnels and Hurley stage III disease benefit from carbon dioxide laser excision or standard surgical excision techniques.

Surgical outcomes demonstrate high patient satisfaction rates exceeding 90%, with recurrence rates at the surgical site remaining low at 4% to 6% when defined as requiring repeat surgery. However, practitioners emphasize that surgery addresses only existing lesions in treated areas and cannot prevent new disease activity in other locations. The optimal approach combines surgical removal of established draining tunnels with biologic therapy to control inflammation, stabilize disease, and reduce the risk of recurrence at surgical sites while preventing new lesion formation elsewhere.

Treatment sequencing involves a pack-and-stack approach for many patients, combining multiple therapeutic modalities simultaneously rather than waiting to see whether individual treatments work sequentially. This aggressive strategy aims to achieve functional disease control as quickly as possible, recognizing that patients have often suffered for years before receiving appropriate care. Practitioners counsel patients that achieving optimal disease control represents a journey requiring 3 to 6 months to a year, even with combination therapy, but emphasize the urgency of initiating comprehensive treatment while managing patient expectations about the timeline for improvement.