Medical and Surgical Management of Hidradenitis Suppurativa

Background: HS is a chronic inflammatory skin disease in which inflammatory nodules and abscesses coexist with tunnels, fibrosis, and scarring. This dual biology explains why medical therapy often improves inflammatory dissease activity without fully addressing fixed tissue damage, whereas surgery can achieve durable local control but does not treat diffuse inflammatory burden. Contemporary international guidelines increasingly endorse multimodal and medicosurgical care. Objective: To critically compare the evidence supporting medical and surgical management of HS, with emphasis on outcomes, indications, limitations, and clinical decision-making relevant to contemporary practice. Methods: A structured review was undertaken using PubMed/MEDLINE, the Cochrane Library, and major dermatology guideline sources, with searches updated to 7 May 2026. Priority was given to clinical guidelines, systematic reviews and meta-analyses, randomized controlled trials, and higher-quality observational studies. Evidence was synthesized narratively because endpoints, populations, and follow-up intervals differed markedly across medical and surgical studies. Results: Medical evidence is strongest for biologic therapy in moderate-to-severe inflammatory HS. Weekly adalimumab improved week-12 HiSCR in the phase 3 PIONEER trials; secukinumab improved week-16 and week-52 outcomes in SUNSHINE/SUNRISE; and bimekizumab improved week-16 HiSCR50 in BE HEARD I/II. Surgical evidence is strongest for wide excision in structurally advanced disease, particularly when compared with local excision or incision and drainage. Meta-analytic data consistently show lower recurrence after wide excision than after local excision, and lower recurrence after flap or graft reconstruction than after primary closure. Combined therapy is increasingly supported: peri-operative adalimumab improved outcomes in SHARPS, and surgery plus adalimumab outperformed adalimumab alone in a pragmatic 12-month RCT. Conclusions: HS is best managed by matching treatment to disease phenotype. Medical therapy is essential for inflammatory control; surgery is essential for persistent tunnels, fibrosis, and scarred regional disease. The strongest overall clinical position is an integrated, multidisciplinary model in which systemic therapy reduces inflammatory load and surgery definitively treats irreversible tissue damage.