Surgical Management of Hidradenitis Suppurativa: Current Evidence and Practical Guidance

Hidradenitis suppurativa is a chronic inflammatory skin disease that frequently progresses from recurrent nodules and abscesses to tunnels, fibrosis, scarring, and substantial quality-of-life impairment. Medical therapy is essential for controlling inflammatory activity, but surgery remains central to the management of structurally irreversible disease. This review summarizes the role of surgery within contemporary hidradenitis suppurativa care, with attention to when surgical referral should occur, how lesion architecture and anatomic site influence procedure selection, and how perioperative biologic therapy can be integrated with operative treatment. Tissue-sparing approaches such as deroofing are most appropriate for localized tunnels, whereas wide excision offers more durable local control for diffuse or deeply interconnected disease. Outcomes are shaped not only by procedure choice, but also by reconstruction strategy, postoperative wound care, anatomic constraints, and access to coordinated multidisciplinary care. The review also discusses evolving areas of interest, including earlier intervention, ultrasound for disease staging and presurgical mapping, and glucagon-like peptide-1 receptor agonists as adjunctive therapy in selected patients with obesity or metabolic comorbidity. Overall, optimal hidradenitis suppurativa surgery depends on individualized procedure selection, integration with medical therapy, and standardized outcome reporting to improve long-term patient care.