Hidradenitis suppurativa (HS) is a complex disease characterized by both structural skin changes and persistent inflammation, necessitating a multifaceted approach to management [1]. With advancements in medical treatment, including antibiotics, hormonal therapy, and biologics, an integrated approach to HS management has developed. Combining surgical management with medical therapy allows clinicians to address both the structural manifestations of HS in addition to the underlying inflammation driving the disease.

Surgical interventions have emerged as a vital component in managing hidradenitis suppurativa (HS), a unique characteristic when contrasted with other chronic inflammatory skin conditions. Surgical treatment can address the distinct types of lesions that characterize HS, including inflammatory nodules, tunnels, abscesses, and scars [2, 3•]. Depending on the size and extent of the lesion, HS surgeries can be performed either in-office under local anesthesia or in an operating room. Surgical approaches vary in terms of technique, extent (lesional or regional), and intent (partial treatment or definitive) [3•]. Simple approaches like incision and drainage can provide immediate relief by draining painful abscesses while deroofing and excision can offer definitive treatment options.

Deroofing is a surgical approach that targets chronic HS changes in the skin and aims to replace areas that are chronically draining or painful with a quiescent scar. The consensus definition for deroofing is “removal of all or the large majority of skin overlying a hidradenitis cavity, with the base left intact following debridement of the base” [4]. Here, the term “cavity” is broad, including lesions such as abscesses and tunnels. The procedure can be conducted using various methods—scalpel, laser, or electrosurgical instruments—including skin-tissue sparing excision with electrosurgical peeling (STEEP) instrumentation [3•, 4]. Similarly, debridement can be achieved via manual friction (such as gauze rubbed on the base), curettage, grattage, laser vaporization, or other techniques [3•, 4]. The intent of deroofing may vary, as complete removal of the entire lesion or affected area may not always be feasible or desirable to the patient in real-world practice [3•, 4]. This means deroofing can target single lesions or entire anatomic regions and be partial (leaving adjacent affected skin behind) or complete (leaving no known cavity or portion of a cavity behind) [5]. Importantly, deroofing leaves the base of the cavity intact [5]. This paper aims to outline a practical approach to deroofing in hidradenitis suppurativa, covering the necessary materials, surgical approach, common complications, and frequent patient queries.