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Hidradenitis suppurativa (HS) frequently affects the skin in the groin — causing pain, scarring, and recurring lesions that can be difficult to treat. When medication and lifestyle changes are not enough to improve HS, surgery may be needed to relieve symptoms.
Dr. Christopher Sayed was interviewed by myHSteam to discuss what people need to know about groin surgery for HS. Dr. Sayed is an associate professor of dermatology at the University of North Carolina at Chapel Hill and a member of the board of directors for the Hidradenitis Suppurativa Foundation.
There are several different surgical procedures used to treat HS. The type of procedure you need depends on the size and extent of lesions that need to be treated. You and your doctor should discuss what type of surgery is best for your situation, including the desired cosmetic results.
“If we are treating a small area that is a few centimeters in size, it is much different than a patient that needs very large excisions and reconstructive procedures. Helping patients understand the size and complexity of the procedure helps in making decisions about how to proceed,” says Dr. Sayed.
Dr. Sayed also described how procedures may be performed in different settings: “We may consider a small or moderately sized procedure with injected anesthesia like lidocaine in the office, but if a patient needs a big procedure or is worried they cannot tolerate the numbing injections, it may be best to consider doing this in an operating room instead.”
Smaller surgeries can be performed as outpatient procedures, but Dr. Sayed noted, “For very large procedures, it is possible you will remain in the hospital overnight or for a few days to help manage the wound and pain for a short time.”
The types of surgery used to treat HS include incision and drainage, punch debridement, unroofing, and excision.
Incision and drainage can provide immediate, temporary relief from extremely painful abscesses, but this procedure does not effectively treat HS lesions. Further medical treatment is needed because lesions are likely to recur.
Punch debridement can effectively remove a single small lesion using only local anesthesia. Using a skin punch, a small (4 to 8 mm) circle of skin is removed. The wound is not stitched closed but is allowed to drain and scar over (healing by secondary intention). This procedure is sometimes called mini-unroofing or limited unroofing. Dr. Sayed uses the term “punch unroofing.”
Unroofing, also called de-roofing, is used to treat abscesses, nodules, larger lesions, and interconnected lesions. A portion of skin and subcutaneous tissue is removed to expose underlying tissue damage and drain sinus tracts that have formed. This procedure can be performed with a local anesthetic.
“Unroofing is typically used for lesions that have been persistent and recurrent for more than a month or two,” Dr. Sayed noted. “It is rarely used for new lesions since most of those are likely to improve without surgery.”
Regional surgical excision can be used to remove large areas of skin with lesions under general anesthesia. “Excisions can also be performed with local anesthesia depending on the size and patient preference,” Dr. Sayed said. For people with severe disease, this may be the best treatment option. This procedure can be used to treat very large areas with many lesions and extensive scarring. Lesional excision focuses on individual lesions and may be performed in an outpatient setting.
Very commonly, the wound is bandaged and allowed to heal by secondary intention, without suturing the remaining skin back together. Although it may sound like this would leave unpleasant scarring, it can result in excellent healing with good cosmetic results. In some cases, larger wounds may need to be covered with skin grafts or skin flaps. However, Dr. Sayed commented, “Sometimes, even for a larger wound [healing by second intention] is more desirable than a large graft or flap that may lead to more scars.”
“Excision is different from deroofing because it typically goes deeper to the fat, whereas deroofings are more often only in the skin,” Dr. Sayed clarified.
Dermatologists typically perform surgery for HS, but other types of doctors may also be involved. For surgeries that require extensive reconstruction, a reconstructive surgeon (plastic surgeon) may be needed.
If lesions are very close to the anus, a colorectal surgeon may be involved to repair damage caused by HS that may affect normal function. For HS lesions in the groin that involve the scrotum, penis, or labia, a urologist or gynecologist may be needed.
Groin surgery for HS is not necessarily much different from other HS surgeries, but there are certain things to consider. The specific location of lesions can make a difference in how surgery is performed and what recovery will be like.
According to Dr. Sayed, recovery from groin surgery is potentially different from other surgeries: “Since the wound might be in an area that makes it painful to sit or do certain activities, it may be more of a challenge to do these things in the first few weeks, but the overall healing process is similar.”
Dr. Sayed also said that “smaller procedures are unlikely to create issues specific to either women or men, but very large reconstructions can have different implications.”
“Men requiring extensive procedures for the scrotum or at the base of the penis may require skin grafting, and the scrotum can heal with a scar-like texture that doesn’t perfectly match typical scrotal skin,” says Dr. Sayed. “For female patients that require removal of most of the labia and pubic area, the scar can become tight and create some discomfort if it creates tension around the vagina.”
Before surgery, make sure you know what you need to do to prepare.
You and your doctor must work together to find out what treatment is best for you. Tell your doctor what you want to achieve from surgery. Dr. Sayed recommends discussing what you feel needs to be treated: “Patients often know the areas that tend to cause the most trouble and have been around for a long time. Pointing this out to the surgeon to make sure they focus on the areas that matter to you most can be helpful.”
When planning your surgery, it is important to consider how extensive the procedure will be. “When multiple or larger areas are affected, it is also important to consider whether you want to have one or two big procedures that result in a bigger recovery all at once, or if you want to break it into smaller steps to make it feel more manageable,” Dr. Sayed explained. “Letting a surgeon know your preference may help them approach these procedures in a way that feels like the best fit for your situation.”
It is also important to know what to expect after your surgery. “Asking about expected wound care and recovery are both important so that expectations are clear,” Dr. Sayed stated. “It can also be helpful to ask about the plan for pain control afterward so that a strategy is in place if needed.” Know what to expect from your recovery, including how long it will take to heal and what you can do to ensure the best outcome.
HS is an inflammatory disease — it is important to control inflammation from HS before having your surgery to avoid potential complications. Having a flare-up at the same time as surgery can lead to worse outcomes.
“It’s often best to make sure the hidradenitis is well-controlled, when possible, ahead of time. It can slow down wound healing and result in bigger wounds if the tissue is swollen and inflamed at the time of surgery,” according to Dr. Sayed.
Medical therapy for HS may be used before and after surgery to reduce inflammation and promote healing. Recent research has shown that using Humira (adalimumab) in conjunction with wide excision surgery is effective at reducing HS symptoms throughout the body.
Some people have a great deal of anxiety before procedures and may need help to stay calm.
Dr. Sayed offered reassurance: “If we do the procedure in the office, medication may be given to help a patient relax.” Make sure to let your doctor know if you need help dealing with the stress of surgery.
For procedures that require general anesthesia, you will be asked not to eat or drink anything beforehand. Your doctor should give you detailed information about what you can and cannot drink for two to eight hours before your scheduled surgery.
Surgery may give you the relief you need, but it may not be immediate. Expect some postoperative pain and the need to be on the lookout for potential complications. You will also need to follow up with your surgeon to track the progress of your healing.
Surgery always carries a risk of complications. Potential complications include infection, bleeding, contractures (scars that limit movement), hematoma (blood clots at the surgical site), and wound dehiscence (re-opening of a sutured wound). Research has shown that, even with more complex surgeries, complications are not very common.
Dr. Sayed points out the importance of keeping an eye out for possible postoperative infection, saying, “Infection is uncommon, but signs include redness, swelling, pain, discharge, and odor that worsen instead of improve after the first few days. These things are all common in the first week or two, but when they get worse instead of better, it can be a sign of a problem.”
He also recommends being careful about postoperative bleeding: “Sometimes, wounds can bleed through a bandage in the first day or two, and it is helpful to limit physical activity in the first 48 hours after surgery to avoid this.”
Dr. Sayed noted that it is important to prevent contractures, explaining, “In the long-term, a large wound may develop a tight or thick scar that can feel restrictive. It is important to increase activity and make sure to stretch the skin in the area each day after the first couple of weeks to make sure the skin around the joints stays mobile as it heals.”
Surgical removal of lesions, especially wide resection, is a definitive treatment for HS. However, HS can still recur after surgery in areas of skin that have not been removed.
One study of 111 people who underwent surgery for HS showed that most were glad they had surgery (96.3 percent) and would recommend it for others. Most people who had HS lesions recur after surgery said that the recurrence was less severe than the original lesions. Perhaps more importantly, self-reported quality of life was significantly improved after surgery.
HS surgery has the potential to greatly improve your quality of life. Your experience may vary, but many people find hope in surgical treatment. HS can be a debilitating disease, so speak with your doctor to find out whether surgery is right for you.
On myHSTeam, the social network for people with hidradenitis suppurativa, more than 23,000 members come together to ask questions, give advice, and share their stories with others who understand life with hidradenitis suppurativa.
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Christopher Sayed, M.D. is an associate professor of dermatology practicing at the University of North Carolina at Chapel Hill. Learn more about him here.
Kristopher Bunting, M.D. studied chemistry and life sciences at the U.S. Military Academy, West Point, and received his doctor of medicine degree from Tulane University. Learn more about him here.
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