Surgical Deroofing for the Management of Hidradenitis Suppurativa: A Systematic Review and Meta-Analysis

To the Editor,

Hidradenitis suppurativa (HS) is a chronic inflammatory dermatosis causing painful nodules, abscesses, and sinus tracts, primarily in intertriginous areas. ¹ Surgical deroofing, a tissue-sparing technique, removes sinus tract and inflammatory nodule roofs to promote healing while reducing pain and recurrence risk. ¹ This systematic review evaluates its efficacy for HS.

This PROSPERO-registered study (CRD42025626552) searched EMBASE, MEDLINE, and CENTRAL from the databases’ inception through November 20, 2024. The Grading of Recommendations, Assessment, Development, and Evaluation scale assessed evidence quality. Random-effects meta-analyses were performed in Cochrane Review Manager (RevMan) version 8.12.0. P < .05 indicated statistical significance. The I² statistic assessed heterogeneity.

Of 178 studies, 17 were included, comprising 677 HS patients treated with deroofing (mean age: 34.2 years; 59.7% female; 100% Hurley stage II-III). Most (n = 662) underwent sharp deroofing, with CO₂ laser (n = 14) and electrocoagulation (n = 1) as alternatives. Comorbidities included diabetes (n = 7; 1.0%), smoking (n = 175; 25.8%), and BMI 19.3 to 36.3 kg/m². Deroofing sites primarily included axillary (37.8%), inguinal (20.3%), and gluteal (14.0%) regions.

Surgical deroofing removed sinus tracts with sharp or energy-based techniques, sometimes ultrasound-guided. Unlike excision, deroofing preserves the lesion floor, promoting quicker secondary intention healing and reducing recurrence risk. ² Postoperative care involved cleaning with hydrogen peroxide or potassium permanganate, and mupirocin ointment application. Dressings for complex wounds included polyurethane foam or gel-forming fiber. Adjunct therapies included topical insulin (100 IU/ml, 0.5 cc/ulcer) and intense pulsed light combined with probe-based radiofrequency.

The average defect size post-deroofing was 52.4 cm² (range 7-67 cm²), with a mean healing time of 29.8 days (95% CI, 13.13-46.56; P = .0005; Supplementary Figure 2)^{1 -4} for sharp deroofing. Healing time averaged 25.9 days in CO₂-laser-assisted deroofing, and 17.5 days in 1 case of electrosurgery-assisted deroofing. Excision with 5- to 10-mm margins and layered closure healed in 28.1 days in 1 study.

Postoperative pain averaged 3.28/10 (95% CI, 0.36-6.19; P = .03; Supplementary Figure 3) on day 1,^{3 -5} 1.1/10 at 1 week, and 0/10 at 3 months for sharp deroofing. On day 1, CO₂-laser-assisted deroofing had a pain score of 1.7/10. ³ Patient satisfaction for sharp deroofing was 8.95/10 (95% CI, 7.09-10.81; P < .00001).^1,5 At 6 months, the Vancouver Scar Scale was not significantly different (P = .11) between surgical (3.4) and CO₂-laser-assisted (2.5) deroofing. ³

Disease recurrence occurred in 22.7% (n = 72/317) of HS-sites at 8.6 months (range 1.2-6.2) post-sharp deroofing. CO₂-laser-assisted deroofing had 10% HS-site recurrence (n = 1/10) at 1 month. ³ In 1 study (n = 405), the recurrence rate was the highest for incision and drainage, and similar between sharp deroofing and excision with margins (hazard ratio 1.0). Excision with margins had recurrence at 14.3% (n = 3/21 HS-sites) between 0.5 and 2 months, and 56.3% (n = 36/64 HS-sites) at 16 months. Major adverse events occurred in 0.3% (n = 2/677) of patients, including postoperative bleeding requiring hospitalization and superinfection post-sharp deroofing.

Overall, this review supports deroofing as an effective and well-tolerated treatment for Hurley stage II to III HS, with favorable outcomes in healing, pain, and satisfaction. Limitations of this study include varied protocols and limited high-quality data. Prospective studies are needed to standardize protocols, evaluate long-term efficacy, and compare with alternative treatments such as excision with margins and layered closure.