Optimizing surgery in hidradenitis suppurativa

Surgery is central to managing the irreversible lesions of hidradenitis suppurativa (HS). Technique should be matched to disease extent: focal procedures (e.g. deroofing) for isolated or localized tunnels; regional excision (e.g. skin-tissue-sparing excision with electrosurgical peeling (STEEP)) for confluent tunnels; and wide excision for extensive disease. This narrative review summarizes the evidence and expert consensus on refining surgical treatment of HS. We discuss patient selection and the 'surgical' window of opportunity, whereby surgery performed at the right time, on medically controlled damaged tissue, yields the best results and involves the least surgical complexity. Pre-operative imaging with high-frequency ultrasound and, in deep or anogenital disease, magnetic resonance imaging allows accurate mapping of tunnels and margins, reducing incomplete excision and local complications. Standardized procedural terminology (lesional versus regional) clarifies the spectrum of techniques, from deroofing and skin-tissue-sparing excision with electrosurgical peeling (STEEP) to wide excision, each with characteristic recurrence rates. Reconstruction is individualized: secondary intention healing remains the workhorse for large defects and facilitates recurrence surveillance, while primary closure, skin grafts and flaps have specific roles and limitations. Post-operative care centres on structured wound-bed preparation, exudate-appropriate dressings and negative-pressure therapy for selected wounds. Finally, combining surgery with targeted systemic therapy is increasingly regarded as a holistic strategy; emerging randomized and observational data suggest improved response rates without a consistent rise in adverse events. We conclude that effective HS surgery is multidisciplinary, imaging-guided, personalized and integrated with medical therapy, and we identify priorities for higher-quality prospective research.