Hidradenitis suppurativa (HS) — sometimes called acne inversa — is a long-term inflammatory skin condition that causes painful lumps under the skin. If medications don’t help control your HS symptoms, surgery may be the next step.

When myHSteam interviewed Dr. Heather Richmond from the Dermatology and Laser Surgery Center in Houston, Texas, we asked her what people should know about hidradenitis suppurativa surgery. Dr. Richmond is a board-certified dermatologist with years of experience treating people with HS. Here’s what she shared about surgical treatment for HS.

Hidradenitis Suppurativa Surgery

HS most often affects the skin in the armpits and groin, beneath the breasts, and between the buttocks. The first signs are usually painful, red nodules (lumps). Over time, they develop into wounds that drain and may form tunnels (called sinus tracts), which can connect one lump to another. Sinus tracts from HS can lead to widespread scarring in the affected areas.

The main types of surgery for HS include:

• Unroofing (or deroofing) — This surgical approach involves removing the top (“roof”) of a sinus tract or abscess. After draining any pus and removing inflamed tissue, the surgeon usually leaves the wound open to heal naturally.
• Punch debridement — This is a minor surgical procedure where the doctor removes small lesions or nodules, along with the hair follicles that caused them, with a round blade. These wounds usually heal quickly.
• Excision — This is a more aggressive surgical technique that removes the entire HS lesion and sometimes the tissue around it. Wide local excision wounds may require stitches to close.
• Incision and drainage — This procedure involves making a small incision (cut) in the affected skin to drain painful nodules and abscesses. While this surgical option can offer short-term relief, it doesn’t prevent flare-ups and isn’t considered a long-term solution for severe cases.

Where your HS surgery takes place depends on a few things, including how complex the procedure will be and what technique is needed. HS surgery might be done in a doctor’s office (like a dermatology clinic), at an outpatient surgery center, or in a hospital operating room. This article focuses on outpatient procedures — not HS surgeries that require anesthesia or an overnight hospital stay.

What To Know Before Surgery

Surgery — even minor surgery — can feel stressful and scary. But knowing what to expect can help ease your worries and prepare you for the best outcome.

Deciding To Have Surgery

Before deciding on surgery for HS, talk with your doctor about all your treatment options. While Dr. Richmond has performed many outpatient surgeries for HS, she reminds people that surgical management of hidradenitis suppurativa is not always the best option.

Preparing for Surgery

As with any surgery, your doctor should explain what will happen in detail and talk about the possible risks and side effects. If they don’t bring it up, make sure to ask. It’s important to understand:

• How to prepare
• What type of anesthesia (if any) will be used
• Whether you’ll need someone to drive you to and from the procedure

Dr. Richmond also advises patients to dress comfortably on the day of surgery. “I recommend loose-fitting clothing that’s not going to rub or press on the surgical site, in order to minimize pain,” she said.

Managing Expectations

Another important part of preparing for surgery is managing expectations. HS surgery can help reduce HS symptoms and improve your quality of life. But it’s not a cure, especially for people with more severe hidradenitis suppurativa.

Cosmetic results — like scarring or skin changes — can also vary. Ask your doctor what your skin might look like after your wounds heal.

Getting Hidradenitis Suppurativa Under Control First

Before surgery, it’s important to reduce inflammation and get your HS flares under control with medical treatment. “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 minimize the size of surgery.”

In some cases, it may be best to delay HS surgery to give medical therapies time to lower inflammation. Keep your long-term goal in mind: a surgery that gives you the best possible results.

What To Know After Surgery

Before your procedure, ask your healthcare provider about possible side effects, complications, and how to care for your wounds after surgery.

Postoperative Complications

“The main complications of HS surgery include infection and wound dehiscence (when a sutured wound opens up),” Dr. Richmond said. “Signs of infection include pain, redness, severe swelling or drainage of pus at the surgical site, and fever. Contact your surgeon immediately in the event of any postprocedural fever.”

She added, “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.”

Dr. Richmond also mentioned the risk of developing a hematoma, which happens when blood collects under the skin. “This causes a bump that has filled with blood,” she explained. Hematomas may need to be drained at the clinic. “External bleeding of the surgical site in general can be an issue,” she added. “With external bleeding, I tell patients to hold firm pressure for about 20 minutes. Most of the time, that stops it.”

If you notice any signs of infection, wounds opening up, bleeding that won’t stop, or other complications after surgery, get medical help right away.

Wound Care

Good postoperative wound care is essential for healthy healing. Wound care varies based on the type of procedure, so ask your doctor for instructions.

In general, Dr. Richmond recommends keeping the surgical wound dry for about 48 hours. After that, you can gently clean it. “Cleanse it gently with soap and water, and dry it off completely,” she said.

Dr. Richmond also recommends applying ointment to surgical wounds before putting on a bandage. “Sometimes, I’ll prescribe a prescription antibiotic ointment. 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, while your wound heals. “Those can allow you to make your own fit-to-size bandages,” she said.

Keeping your bandage in place is also important. Dr. Richmond recommends surgical tape for this. “There’s one called Hypafix, which is a stretchy adhesive,” she said. “Or paper tape, for patients who tend to have adhesive sensitivity.” You can find wound dressings and surgical tape like these at your local pharmacy or online. Your provider can also tell you if your insurance covers wound care supplies.

How often you change your dressings depends on your healthcare provider’s instructions. In general, dressings should be changed daily, every other day, or sooner if they become soaked with blood or fluid.

For more extensive surgeries, such as wide excision surgery that removes large portions of skin, you may need special wound care. Procedures that use skin grafts or skin flaps also require special care.

Some wounds are more likely to scar, especially depending on where they are and how they’re closed. In some cases, scarring can limit the movement of a joint — this is called a contracture. Talk to your doctor about ways to keep your flexibility and range of motion during recovery.

Postoperative Pain

According to Dr. Richmond, it’s normal to have some pain during the first 48 to 72 hours after surgery. The amount of pain and how long it lasts may depend on what type of surgery you had. Some people say their postoperative pain was no worse than a severe HS flare-up.

“Most of the time, the pain is really tolerable unless you’re having some kind of healing issue, infection, or extreme tension,” Dr. Richmond said.

To manage pain, you can use over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil or Motrin), naproxen (Aleve), or acetaminophen (Tylenol). If these medicines don’t help, talk to your doctor. Ongoing or worsening pain could be a sign of infection or another problem. You may need prescription pain relief or a follow-up exam.

“I always tell patients I’m available for calls,” Dr. Richmond continued. “If something doesn’t 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.”

Postoperative Follow-Up

Follow-up care is key to making sure your wound heals properly. Ask your doctor 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.”

Talk With Others Who Understand

On myHSteam, the social network for people with hidradenitis suppurativa and their loved ones, members come together to ask questions, give advice, and share their stories with others who understand life with hidradenitis suppurativa.

Are you or someone you care for living with hidradenitis suppurativa? Share your experience in the comments below, or start a conversation by posting on your Activities page.