Surgical Management of Hidradenitis Suppurativa Using Staged Carbon Dioxide Laser Marsupialization

Background: Hidradenitis suppurativa (HS) is a chronic disease marked by symptoms of pain, drainage, and odor. Persistent abscesses, nodules, and scarred tunnels can be resistant to pharmacologic management, with chronic lesions often requiring complex surgical intervention. Treatments include en bloc excision with primary closure, tissue flaps or skin grafts. Such procedures are associated with post-operative challenges, including pain, infection, contractures, and high recurrence rates. Methods: Herein we report use of continuous-wave carbon dioxide (CO₂) laser for HS tissue removal, during which there is an initial full-thickness excision of clinically evident lesions of hidradenitis, followed by the intra-surgical identification and staged removal of additional areas, resulting in a pocket-like (marsupialized) defect. We named the procedure staged carbon dioxide laser marsupialization (SCLM). Results: Five hundred twenty-seven patients underwent a total of 992 laser surgery sessions to manage 1846 treatment sites using SCLM. All but six patients were Hurley Stage II or III. The commonly treated sites included the groin (29.4%), axillae (27%), and buttocks (10.9%). A histomorphometry analysis of a subset of tissues revealed an average depth of HS tunnels of 3.34 mm. All post-SCLM wounds healed by secondary intention, with full healing achieved in 6-16 weeks. No instances of post-operative infection occurred. Documented surgical-site recurrence occurred in 1.4% of treated sites during available follow-up. Conclusions: Staged carbon dioxide laser marsupialization for removal of lesions of HS is an encouraging treatment approach for patients with moderate-to-severe HS, with an excellent quality of healing, no infection risk, minimal post-surgical complications, and low frequency of documented surgical-site recurrence.