10 Procedural Tips for Hidradenitis Suppurativa

Key Takeaways

• Incision and drainage with a punch tool provides effective short-term relief for acute hidradenitis suppurativa (HS) abscesses, while deroofing or excision offers more definitive management for chronic or tunneled disease.
• Careful preoperative planning and alignment of surgical extent with patient expectations may reduce recurrence.
• Deroofing is often tissue-sparing and is associated with quicker recovery than excision; it may also yield comparable outcomes for appropriately selected lesions.
• Meticulous technique is critical to minimizing pain, complications, and recurrence.

Hidradenitis suppurativa (HS) is a chronic inflammatory condition with multiple medical and surgical treatment options. For acute, tense abscesses, an incision and drainage procedure can be beneficial to provide symptomatic relief. For persistently chronic lesions, a more definitive deroofing or excision may be required to decrease recurrence of disease. If a patient is interested in surgery, it is important to discuss medical therapy in addition to surgical options to help prevent future lesions at the treated site or other anatomical locations. This guide was created to assist dermatologists who care for patients with HS considering surgery and emphasizes the importance of patient-centered care, expectation setting, and advanced surgical techniques. 

1. PLAN ACCORDINGLY
Patients frequently present with a heterogenous interventional history for HS. Most patients are aware of the extent of recurrent or persistent sites of disease that may be subtle on initial examination. Prior to any procedure, visually inspect and palpate carefully for areas of dermal firmness, particularly with overlying erythema, violaceous color, or hyperpigmentation, which is often a sign of underlying tunnel extension. Use a marking pen to indicate the area of suspected involvement and have the patient view the area with a mirror to confirm that it matches their expectation of involved areas, especially paying attention to areas they indicate have frequent recurrence/persistence. When disease is extensive or affects many areas, consider the patient’s preference for multiple smaller procedures with simpler recoveries versus fewer, larger procedures with more intense recoveries. It is important for any procedure to be compatible with the patient’s lifestyle and aligned with their preferences.

2. CONSIDER A DOSE OF BENZODIAZEPINE FOR A LARGER PROCEDURE

For an in-office procedure, patients may be anxious about the use of injections for local anesthesia, especially for larger procedures. If a patient has a driver and no contraindications for benzodiazepines, consider a preoperative anxiolytic, such as diazepam (5–10 mg, adjusted for body weight and patient history), administered 30–60 minutes prior to the procedure. This should be e-prescribed to the patient’s pharmacy in advance to ensure timely administration. If nitrous oxide is available, this can also be considered. It is important to discuss this with the patient prior to the day of the procedure to allow sufficient time for the prescription to be filled. 

3. INJECT LOCAL ANESTHESIA SLOWLY AND SUPERFICIALLY BEFORE ADVANCING DEEPER FOR AN INCISION AND DRAINAGE PROCEDURE

Incision and drainage procedures are beneficial for acute abscesses to provide the patient with symptomatic relief. When preparing for the incision and drainage, look for any signs of atrophy or where the patient indicates they think the lesion is most likely to drain soon as the target location for local anesthesia (see Figure 1). Prior to injection, place an ice pack on the area for about 8-10 seconds and/or use topical anesthesia to help relieve the pain from the injection. Start the injection very slowly and very superficially and raise a gradual wheal before advancing slightly deeper to numb the area over the abscess where the incision will be made rather than injecting into the middle of the abscess first. 

Figure 1. Extensive local anesthesia: Using 0.25% lidocaine with epinephrine and a 30-gauge, 0.5-inch needle, a small area is anesthetized. Next, a 25-gauge, 1.5-inch needle is used to pierce a previously anesthetized area and to fan out to inject a larger area with fewer injection sites.

4. USE PUNCH TOOL FOR INCISION AND DRAINAGE PROCEDURES WHILE AVOIDING PACKING POSTOPERATIVELY

When performing an incision and drainage, a 6-mm punch tool can be helpful for the initial incision (see Figure 2). This circular opening can allow the lesion to be expressed more effectively and allows it to drain for a few days after instead of refilling following a small incision with a blade. Once the abscess has initially drained, perform manual palpation to express remaining debris from the lesion. Routine wound packing is not recommended; data extrapolated from randomized controlled trials of cutaneous abscesses indicate that packing significantly increases postoperative pain without improving healing or recurrence rates.1 Pro tip: cover the back of the punch tool with gauze during the procedure to make sure pus does not leak through the instrument.

Figure 2. Use of a 6-mm punch tool for incisions and drainage. Rapid drainage is achieved and a small wound left to heal by secondary intention prevents short-term refilling of the abscess.

5. CONSIDER DEROOFING VERSUS EXCISION FOR MORE EXTENSIVE LESIONS

For larger lesions, deroofing and excision are surgical options. Deroofing removes diseased skin covering a tunnel or abscess but does not remove the full thickness of the skin in most cases. Excision removes the entire lesion including full-thickness skin. Deroofing can spare tissue compared to an excision. The deroofing procedure involves probing all procedural areas; opening the skin over the top of the tunnel with scissors, blade, or other tool; and then gently debriding the gelatinous material before allowing the area to heal by secondary intention. This method usually leads to a quicker recovery compared to excision with similarly effective outcomes. 

6. ADAPT LOCAL ANESTHESIA FOR LARGER PROCEDURES SUCH AS DEROOFING AND EXCISION

Local anesthesia for deroofing or excisions can be time intensive and painful for the patient (Figure 3). It is important to gauge the patient’s pain tolerance and check in with them throughout the numbing process. For these procedures, start with a small needle, such as a 30-gauge, 0.5-inch one. Once a small area is numb, use a 25-gauge, 1.5-inch needle to fan out and numb larger areas. Avoid piercing skin with a larger needle for areas that are not already anesthetized as this will help patients feel less pain during this process. For larger cases, use lidocaine 0.5% or 0.25% to avoid lidocaine toxicity. A 10 mL syringe is preferred rather than multiple 3 mL or 5 mL syringes to limit the number of syringes needed.

Figure 3. Deroofing procedure. A) Following anesthesia, a double-ended probe is used to delineate areas, targeting areas with obvious drainage, atrophy, or dimpling. B) Scissor is used to incise the area over the probe, or one arm of the scissor can be used to probe and cut simultaneously. C) Explore for extension of tunneling. D) Final wound in the dermal plane following debridement of gelatinous material (when present) with gauze.

7. PROBE TO DETERMINE EXTENT OF TUNNELS
Following anesthetization, use instruments such as a double-ended malleable surgical probe or iris scissor to probe all tunnel openings to delineate extent of involvement. Throughout the procedure, look for any areas of gelatinous material at the borders or other signs of extension and continue to probe until the area seems completely clear. A long cotton swab can also be used to probe as diseased skin continues to be removed. 

8. LOOK FOR ANY REMAINING COMEDONES PRIOR TO ENDING THE PROCEDURE
Prior to ending the procedure, examine the area for additional prominent comedones or dimples near the edge of the treated area. Probing with a narrow instrument such as the tip of an iris scissor can be helpful as these comedones are often subtle openings that connect to a larger tunnel. If these areas are not removed, a patient may be at a higher risk for recurrence (Figure 4).

Figure 4. Persistence following prior surgery with a nearby pit that connected to the wound edge. The yellow arrow indicates a pit in the inguinal crease. Red dashes indicate an underlying tunnel connecting to wound.

9. CONTROL BLEEDING PRIOR TO BANDAGING WITH OPTIMAL HEMOSTATIC METHODS
After finishing the procedure, assess the patient’s bleeding status. If the patient continues to bleed, perform hemostatic measures to stop bleeding. Aluminum chloride hexahydrate (eg, Drysol) can be used to stop initial bleeding over the wound. Electrocautery is often necessary as well. If aluminum chloride hexahydrate was used prior to electrocautery, ensure the lesion is completely dry prior to electrocautery use, especially if the solution is alcohol-based, to avoid injury. Monsel’s solution, compounded topical tranexamic acid, and absorbable gelatin sponges (eg, Gelfoam) can also be used as needed.

10. ENSURE PROPER WOUND CARE WITH PRESSURE DRESSINGS AND POSSIBLE POSTOPERATIVE PAIN MEDICATIONS 

Once hemostasis has been obtained, the patient is ready for a bandage. A pressure bandage is recommended for the first 24 hours to help prevent future bleeding. This can be obtained from a simple bandage with petrolatum, non-stick gauze, abdominal pad, and cloth retention tapes such as Hypafix or Medipore. Similar bordered gauzes are often ideal and inexpensive. Compression shorts to hold bandaging in place may be appropriate for the groin or perianal area, or wound care systems tailored for HS patients such as HidraWear can be considered to reduce irritation from adhesives. It is important to be flexible if a patient has a preference on their bandaging as many patients have an extensive history of bandaging HS lesions. For pain management, consider 8-12 tablets of short-acting opiate in addition to ibuprofen and acetaminophen. A newer medication, suzetrigine, may be beneficial as a non-opiate option; however, data in HS patients after a procedure are limited, and cost may be a hindrance to obtaining this medication. 

1. O’Malley GF, Dominici P, et al. Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Acad Emerg Med. 2009;16(5):470-3. doi: 10.1111/j.1553-2712.2009.00409.x. Epub 2009 Apr 10. PMID: 19388915.

Emily G. Summers

• Medical student
• University of North Carolina at Chapel Hill School of Medicine

Christopher J. Sayed, MD

• Professor of Medicine, Department of Dermatology
• University of North Carolina at Chapel Hill School of Medicine