Hidradenitis suppurativa (HS) — sometimes called acne inversa — is a chronic inflammatory skin condition that causes painful lumps that develop under a person’s skin. When medications fail to control someone’s HS symptoms, surgery may be their best option.
When myHSteam interviewed Dr. Heather Richmond of the Dermatology & Laser Surgery Center in Houston, Texas, we asked about hidradenitis suppurativa surgery. We wanted to find out what everyone with HS should know —and expect — about the surgery. Dr. Richmond, a board-certified dermatologist with years of experience treating people with HS, laid it all out for us. Here’s what she shared.
Hidradenitis suppurativa most commonly affects the armpits, skin beneath the breasts, groin, and between the buttocks. But it can also occur in other areas with hair follicles. Lumps caused by HS begin as painful, red nodules (lumps) in the skin. These develop into wounds that drain and form tunnels (called sinus tracts) from one to another. Sinus tracts from HS can lead to widespread scarring in the affected areas.
Surgery to treat HS involves creating an incision (cut) to drain painful nodules and abscesses. It can also include “deroofing” to expose sinus tracts. (In this procedure, a surgeon removes the top, or “roof,” of an abscess to drain it.) In some cases, a surgeon removes lesions along with nearby skin altogether.
Where the surgery is performed depends on a few things, including how complex the procedure might be and the technique needed to complete it. Based on those, HS surgery can take place in a doctor’s office (like a dermatology clinic), at an outpatient surgery center, or in an operating room. In this article, we look at outpatient procedures — not the HS surgeries that require anesthesia or a hospital stay.
Surgery, no matter how minor, can be stressful and scary. Knowing what to expect from your surgery and how you should prepare helps some people.
Before you have surgery for HS, it’s important to discuss your treatment options with your doctor. Even though Dr. Richmond has extensive experience performing outpatient surgery for HS, she warns that surgical management is not always the best way to treat HS.
Before opting for a surgical solution, Dr. Richmond said she asks herself a few questions about the patch of HS nodules and tunnels she’s treating. “Is this a place we should operate on or not? Is it a place that’s always there that doesn’t ever go away?” she considers.
Chronic lesions that occur in the same patch over months or years make good candidates for surgery, according to Dr. Richmond. “If the lesions are moving around,” she countered, “I would strongly consider maximizing your medical therapy as much as you possibly can.”
As with any other surgery, your doctor will go over the details of the procedure and explain the risks and possible complications of surgery. (If they don’t cover these things, ask them to do so.)
Ask questions about your HS surgery, whether you can eat or drink before surgery, and if you should stop taking any medications the day of your procedure or before. Be certain that you understand what types of anesthesia (if any) will be used. And find out if you will need someone to go with you or drive you (to and from) the procedure.
Dress comfortably the day of your surgery. “As far as clothing, I would recommend loose-fitting clothing that’s not going to be rubbing or pressing on the surgical site in order to minimize pain,” said Dr. Richmond. Remember that postoperative drainage may seep into your clothes if your wound dressings fill with blood and other fluids. (This does not normally occur right after surgery, but it can be a risk.)
Another important part of preparing for surgery is managing your expectations. For someone with HS, surgery does not equal a cure. And while HS is a skin condition, it is also an inflammatory disease that can affect the body in other ways — swelling, itching, and more.
Cosmetic results after surgery can vary. Before you choose this surgery, ask your doctor about what to expect when your scars heal.
Overall, HS surgery can improve your symptoms, quality of life, and ability to enjoy activities that your condition hinders.
Before surgery, it’s important to reduce inflammation and get your HS flares under control with medication. “If I’m going to be excising a lesion entirely,” said Dr. Richmond, “I like to try to do it when it’s less inflamed … so you’re not having as much postoperative pain, reduce complications, and to minimize the size of surgery.”
In some cases, it may be better to delay surgery for HS to give medical therapies time to reduce inflammation. Keep the goal in mind: a surgery that achieves the best possible results.
After any surgery, wound care is critical to healthy healing. Also, cosmetic outcomes can be affected by how a wound heals.
Regarding HS surgery, Dr. Richmond said, “The main complications include infection and wound dehiscence (or opening up of a sutured wound). Signs of infection include pain, redness, severe swelling or drainage of pus at the surgical site.”
Additionally, Dr. Richmond noted, “Fever is also a very important sign of infection, and you should contact your surgeon immediately in the event of any postprocedural fever. A good tip is to monitor if the wound is becoming more painful — pain is a really good indicator of infection. Although some postoperative pain is expected, it should improve over time rather than worsen.”
“If the surgical site is stitched closed,” Dr. Richmond continued, “there is a risk of the wound opening, which sometimes can happen in areas that are in the folds of the body where there’s a lot of friction. So you can either have the stitches pop or the wound break down around the stitches.”
Dr. Richmond also touched on the risk of developing hematoma (a pooling of blood underneath the stitches). “This causes [a] bump that has filled with blood,” she said.
Hematomas may need to be drained in the clinic. “External bleeding of the surgical site in general can be an issue,” Dr. Richmond added. “With external bleeding, I tell patients to hold firm pressure for about 20 minutes, and most of the time that stops it.”
If you have any signs of infection, wounds opening up, bleeding that won’t stop, or other complications after surgery, get immediate medical help.
Good postoperative wound care is essential for healthy healing after surgery. Wound care varies based on the type of procedure you underwent.
For example, Dr. Richmond said, “If we’re doing the deroofing type procedures, the recommendation is to let it heal from ‘second intent,’ which means that it’s not closed up with stitches and heals from the bottom up and the sides in.”
Healing after deroofing, Dr. Richmond said, can take time. “Depending on how big [the surgical wound] is,” she said, “potentially [requiring] weeks for healing.”
On the plus side, a person’s postoperative pain tends to be relatively short-lived after deroofing. “The pain can be more significant in the first couple of days,” said Dr. Richmond, “but it actually tends to feel better as long as you’re doing proper wound care.”
Other surgeries, such as excisions, require sutures (stitches) to close the surgical wound. This is called a “primary closure.” In these closures, a person’s postoperative pain should be temporary. Dr. Richmond said to expect some amount of pain for the first 48 to 72 hours. However, she warned, “Most of the time, it’s really tolerable unless you’re having some kind of healing issue, infection, or extreme tension.”
To care for a sutured surgical wound, Dr. Richmond shared specific directions. Keep the surgical wound dry for about 48 hours, she advised. Then tackle cleaning. “Cleanse it gently with soap and water, and dry it off completely,” she said.
Depending on the location of your surgical site and its type of closure, some wounds may be prone to scarring. That can lead to contractures — scarring that limits movement of a joint. Talk to your doctor about how to maintain your flexibility and range of motion after surgery.
Dr. Richmond recommends applying ointment to surgical wounds before you dress them. “Depending upon the location,” she said, “sometimes I’ll [prescribe] a prescription antibiotic ointment, such as mupirocin. But a lot of times I’ll recommend just Vaseline or Aquaphor to keep the area from drying out.”
Dr. Richmond recommends using non-stick, non-adhering dressings, such as Telfa pads. “Those,” she said, “can allow you to make your own fit-to-size bandages.”
Keeping your dressing in place is also important. To do so, Dr. Richmond suggests surgical tape. “There’s one called Hypafix, which is a stretchy adhesive,” she said. “Or paper tape for patients who tend to have adhesive sensitivity.” Find various wound dressings and surgical tape at your pharmacy and other such stores or via online retailers.
How often you change your dressings depends on your health care provider’s directions. Generally, a dressing should be changed daily, every other day, or even sooner if it has become saturated with surgical wound blood and/or fluid.
Extensive surgeries, such as wide excision surgery that removes large portions of skin, may require special wound care. That might involve things like making three dressing changes per day. Procedures with skin grafts or skin flaps also require special doctor-directed care.
Surgery follow-up is essential to ensure that your wound heals properly and so you can avoid complications. Your doctor will let you know when to come back for your post-op follow-up.
“If I’m doing an excision with stitches, most of the time the stitches come out two weeks later, so that’s when we’ll do our follow-up,” Dr. Richmond said. “I’d probably do a similar follow-up, two to three weeks, if I do an unroofing or debridement procedure.”
“I always tell patients I’m available for calls,” Dr. Richmond continued. “If something does not feel right, if something is very painful, if something seems infected, [they] should call me right away and I will help manage it over the phone, [or] bring [them] into the clinic.”
Dr. Richmond knows that life with HS can be difficult. “It’s painful, it’s really impactful to daily life and there’s an embarrassing factor,” she said. “So some people are hesitant to talk about it.” But, she emphasized, “You’re not alone. It’s a really common problem that I think people don’t talk about.”
MyHSteam is the social network for people with hidradenitis suppurativa and their loved ones. On myHSteam, more than 24,000 members come together to ask questions, give advice, and share their stories with others who understand life with hidradenitis suppurativa.
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