Management Challenges and Surgical Role in Hidradenitis Suppurativa: A Comprehensive Review

Hidradenitis suppurativa is a chronic, relapsing, inflammatory disorder of the follicular unit that produces painful nodules, abscesses, draining tunnels and permanent scarring in intertriginous skin. Despite substantial therapeutic progress, disease control remains difficult because hidradenitis suppurativa is clinically heterogeneous, commonly diagnosed late, tightly linked to obesity, smoking and metabolic comorbidity, and associated with a symptom burden that extends beyond inflammatory lesion counts to pain, odour, drainage, psychosocial distress and functional limitation. Medical therapy has expanded from antibiotics and adjunctive anti-inflammatory regimens to biologics and emerging targeted small molecules, yet established tunnels and scarred tissue often remain only partially reversible. For this reason, surgery should not be regarded solely as salvage therapy for end-stage disease, but as a core component of staged management for selected lesions and anatomical regions. This narrative review examines the principal management challenges in hidradenitis suppurativa and critically appraises the contemporary role of surgery within an integrated care pathway. A structured literature search of PubMed, Scopus, Web of Science and Google Scholar was undertaken for publications since January 2000 to present, with emphasis on guidelines, randomised trials, meta-analyses, cohort studies and recent high-quality reviews relevant to epidemiology, burden, medical therapy and operative care. The review discusses why current treatment pathways often fail, including diagnostic delay, discordance between inflammatory activity and structural damage, limitations of conventional outcome measures, fragmentation of multidisciplinary care and variable access to procedural expertise. It then evaluates deroofing, limited excision, wide excision, laser-based procedures and reconstructive strategies, alongside perioperative integration with systemic therapy. The available evidence supports a shift from a linear “medical first, surgery last” model towards phenotype-driven, anatomy-specific and temporally coordinated care. Tissue-sparing procedures are valuable for localised tunnels and recurrent nodules, whereas wide excision remains important for extensive tunnelled or scarred disease. Reconstruction and wound-healing choices should be individualised according to site, contamination, function and patient goals. Perioperative biologic therapy, particularly adalimumab in selected candidates, appears feasible without mandatory interruption. The best long-term outcomes are most likely to arise from early recognition of irreversible lesions, joint planning by dermatology and surgery, rigorous risk-factor optimisation and continued postoperative medical suppression of disease activity beyond the operative field.