Two‐Stage Surgical Management of Anogenital Hidradenitis Suppurativa in Patients on Biologic Therapy: A Retrospective Case Series

ABSTRACT

Hidradenitis suppurativa is a chronic inflammatory skin disorder causing painful nodules, abscesses and scarring, with the anogenital region presenting particular functional and reconstructive challenges. Although biologic therapy is commonly used in moderate to severe disease, its limitations highlight the role of surgery in advanced cases. This single‐centre retrospective case series included five male patients with Hurley stage III perineal, anorectal, genital or gluteal disease treated surgically between 2021 and 2023 following failure of biologic therapy. Management consisted of two‐stage radical excision, negative‐pressure wound therapy and reconstruction with meshed split‐thickness skin grafts. All patients achieved more than 90% graft take and complete wound healing. No recurrence occurred during a median follow‐up of 19.2 months. One patient developed a keloid scar at the donor site, and one experienced delayed healing. Functional and aesthetic results were satisfactory in all cases. Two‐stage surgical excision with split‐thickness skin graft reconstruction was associated with sustained wound healing and favourable functional outcomes in selected patients with severe anogenital hidradenitis suppurativa refractory to biologic therapy.

Key Points

• Radical staged excision combined with negative‐pressure wound therapy enabled effective wound bed preparation in severe anogenital hidradenitis suppurativa.

• Delayed split‐thickness skin grafting achieved reliable wound closure following optimisation with negative‐pressure wound therapy.

• A structured multidisciplinary surgical approach may provide sustained local control in advanced disease refractory to systemic therapy.

1. Introduction

Hidradenitis suppurativa (HS), also known as acne inversa, is a chronic inflammatory skin disorder with an estimated prevalence of 0.5%–1% of the population [1]. The disease typically begins in early adulthood [2, 3] and is characterised by painful nodules, abscesses, sinus tracts, fistulas and scarring in apocrine gland‐bearing areas [4]. Lesions in the genital, inguinal and gluteal regions are particularly difficult to manage because of anatomical and functional challenges, requiring multidisciplinary collaboration between dermatologists, surgeons and other specialists [5, 6, 7].

Early‐stage HS can often be controlled with antibiotics, retinoids, corticosteroids or hormonal therapy [5, 8]. In moderate to severe or refractory disease, biologic therapy is recommended as a second‐line option [9, 10]. At the time when this study was conducted, adalimumab, a monoclonal anti–TNF‐α antibody, was the only biologic agent approved by the FDA and EMA for HS [11]. Despite demonstrated short‐term efficacy, biologics are limited by secondary loss of response, recurrence after discontinuation, side effects and paradoxical HS [9, 10, 12, 13].

In patients with severe, chronic and irreversible lesions, surgery remains the only definitive treatment. Available techniques include incision and drainage, deroofing, tissue‐sparing excision, CO₂ laser excision and radical excision with or without reconstruction [5, 14]. As current literature provides limited evidence on the surgical outcomes of patients previously treated with biologic therapy, this study reports our experience with two‐stage surgical management in such cases.

2. Materials and Methods

This was a single‐centre, retrospective observational case series conducted in accordance with the STROBE reporting guidelines for observational studies.

This retrospective review included patients with severe HS treated at the University Hospital Centre Zagreb, Croatia, between 2021 and 2023. The study was exempt from formal approval by the local ethics committee, as it involved retrospective analysis without direct patient intervention. Written informed consent for the use of anonymised clinical data and images was obtained from all patients, and the study was conducted in accordance with the principles of the Declaration of Helsinki.

2.1. Patient Selection

Male patients with perineal, anorectal, genital or gluteal HS who had received biologic therapy and were referred for surgical management after disease progression were identified. The study focused on patients requiring complex, staged surgical management for extensive anogenital defects. All consecutive patients who met these criteria during the study period were included, with no additional exclusion criteria applied. During the study period, one female patient with Hurley stage III disease was treated surgically. However, the extent of tissue involvement did not require staged or prolonged reconstructive management. As the present analysis was limited to patients undergoing complex multistage procedures for extensive defects, this case was excluded in the final cohort. Clinical data included demographics, comorbidities, type of biologic therapy, surgical outcomes, histopathological findings and microbiological results. Disease severity was assessed according to Hurley staging (Figure 1). All patients had prior adalimumab therapy according to institutional protocols; no dose escalation, switching or combination biologic regimens were applied.

FIGURE 1.

Hurley stage III. Penile skin lymphedema (A) together with involvement of the scrotum and perineum with multiple abscesses (B). Extensive scars with sinus and fistula formation of the gluteal region (C).

All patients were evaluated by a multidisciplinary team comprising a dermatologist, a plastic surgeon, an abdominal surgeon and a urologist. Surgical treatment was undertaken following discontinuation of biologic therapy, which was not resumed postoperatively.

2.2. Surgical Protocol

All procedures were performed under general anaesthesia using a two‐stage approach.

Stage 1 involved radical excision of all diseased tissue with preservation of the underlying fascia where feasible (Figure 2A–C). Preservation of bowel continuity was prioritised whenever possible. A temporary diverting colostomy was reserved for cases with extensive perineal or anorectal involvement, particularly when lesions were located in close proximity to the anal verge and adequate isolation of the reconstructed area from faecal contamination and anal secretions could not be ensured. Wound management was achieved with negative‐pressure wound therapy with instillation and dwell time (NPWTi‐d) (Figures 2D and 3). NPWTi‐d was performed using a low‐concentration chlorine‐based releasing solution as the irrigation fluid. The instillation volume was individually adjusted according to defect size. A dwell time of 20 min was applied, followed by continuous negative pressure at −125 mmHg (medium intensity).

FIGURE 2.

Resection of entire diseased tissue together with negative pressure closure. Avoiding injuries to glans, corpora cavernosa, spongiosa and preserving tunica vaginalis layers of spermatic cord and testes (A and B). Taking care to evade any harm to anal sphincter muscle (C). Wound closure using NPWTi‐d (entire system is not covered by photography) (D). NPWTi‐d, negative‐pressure wound therapy with instillation and dwell time.

FIGURE 3.

Interoperative wound care with NPWTi‐d. Wound healing with progression of healthy granulations (A). Few days after surgery stage 1 (B) and last day of negative pressure therapy before surgery stage 2 (C). NPWTi‐d, negative‐pressure wound therapy with instillation and dwell time.

Stage 2 was performed approximately 2 weeks later, once healthy granulation tissue was observed and microbiological results were deemed satisfactory following targeted antimicrobial management (Figure 3C). Reconstruction was carried out using meshed split‐thickness skin grafts (STSG) harvested from the thigh (Figure 4A,C). Grafts were applied to central areas, while peripheral zones were allowed to heal by secondary intention (Figure 4A,B). Negative‐pressure wound therapy (NPWT) was applied over the grafts for 5 days (Figure 4C).

FIGURE 4.

Wound reconstruction using STSG and NPWT. Marginal areas left to heal by secondary intention. Meshed graft used for penile skin replacement (A and B). Graft donor sites (A and C). Installation of NPWT system (entire system is not covered by photography) (C). STSG, split‐thickness skin graft; NPWT, negative‐pressure wound therapy.

2.3. Postoperative Care and Follow‐Up

All patients received perioperative antibiotic prophylaxis and nutritional support according to institutional protocols. Donor sites were managed conservatively. Patients were instructed in home wound care and followed jointly by dermatology and surgical teams.

2.4. Outcomes

Primary outcomes included:

• Graft take—the percentage of viable graft surface assessed on postoperative day 5, considered successful if > 90%.

• Wound healing—complete epithelialisation of recipient and donor sites.

• Recurrence—development of new clinically active HS lesions within the surgically treated area during follow‐up. Scar irregularities or hypertrophic scar changes without clinical signs of inflammation were not considered recurrence.

• Histopathology and microbiology—evaluation of excised tissue for malignancy and microbiological analysis of intraoperative wound swabs.

• Complications—adverse events related to surgery, grafting or donor site.

• Function and patient satisfaction—assessed by patient self‐report during follow‐up visits.

Given the small sample size, data are presented descriptively without statistical analysis. Representative images of surgical steps and long‐term outcomes are shown in Figures 1, 2, 3, 4, 5.

FIGURE 5.

Final outcome of our surgical approach. 2 months postoperatively: secondary intention healing areas are healing without infection; grafted areas are covered with minimal fibrin (A). 2 years postoperatively: no major obstacle in sexual function (B). 3 years postoperatively: grafted area healed completely allowing regular bowel movement (C and D).

3. Results

Five male patients with genital, perineal, anorectal and gluteal HS underwent two‐stage surgery between 2021 and 2023. The median age was 47 years (range, 34–65). All patients were active smokers and classified as Hurley stage III [15]. Each had previously received adalimumab (40 mg weekly) [11] prescribed by a dermatologist, with no dose escalation or combination therapy applied.

Following surgical treatment, biologic therapy was permanently discontinued in all patients. The median follow‐up period was 19.2 months (range 10–36), and no patients were lost to follow‐up.

3.1. Histopathology and Microbiology

All excised specimens revealed benign, chronically inflamed tissue without evidence of carcinoma. A total of 27 different bacterial species were identified from wound swabs, including both aerobic and anaerobic flora. One patient presented with methicillin‐resistant Staphylococcus aureus (MRSA) infection, which resolved prior to definitive closure. Serratia marcescens was isolated from intraoperative wound swabs in one patient. These microbiological results guided antimicrobial therapy and informed surgical planning, including the duration of NPWTi‐d and the timing of STSG placement.

3.2. Surgical Outcomes

All patients achieved more than 90% graft take and complete wound healing, defined as full epithelialisation of recipient site without persistent drainage. One donor site developed a keloid scar, which was successfully treated with intralesional triamcinolone and scar massage. One patient experienced delayed wound healing in a small perineal area. No major complications occurred.

3.3. Recurrence and Function

During follow‐up, no clinically active HS lesions were observed within the operated areas. All patients reported satisfactory cosmetic outcomes, preserved sexual and urinary function, and overall satisfaction with the results. Functional outcomes and patient satisfaction were assessed through routine clinical follow‐up and patient self‐report; no validated quality‐of‐life or functional assessment instruments were applied. Representative postoperative images are presented in Figure 5.

3.4. Summary of Cases

Clinical characteristics and surgical outcomes of all patients are summarised in Table 1.

TABLE 1.

Clinical characteristics, treatment details and outcomes of patients with severe anogenital hidradenitis suppurativa treated surgically after biologic therapy failure.

Patient	Age (years)	Sex	Smoker	Hurley stage	Defect location	Prior biologic therapy	Comorbidity	Surgical complications	Follow‐up (months)	Outcome
1	34	M	Yes	III	Genital, perineal	Adalimumab 40 mg weekly	Pilonidal sinus	None	10	No recurrence, satisfied
2	36	M	Yes	III	Anorectal, gluteal	Adalimumab 40 mg weekly	Pilonidal sinus	Keloid scar (donor site)	20	No recurrence, satisfied
3	42	M	Yes	III	Genital, perineal, anorectal	Adalimumab 40 mg weekly	Pilonidal sinus	MRSA infection (resolved)	15	No recurrence, satisfied
4	58	M	Yes	III	Genital, perineal, anorectal	Adalimumab 40 mg weekly	Pilonidal sinus	Delayed wound healing	15	No recurrence, satisfied
5	65	M	Yes	III	Perineal, anorectal, gluteal	Adalimumab 40 mg weekly	None documented	None	36	No recurrence, satisfied

Abbreviations: M, male; MRSA, methicillin‐resistant Staphylococcus aureus .

4. Discussion

HS in the anogenital region severely impairs quality of life and often requires interdisciplinary management. In recent years, biologic therapy has become a major treatment option, with reported adalimumab efficacy rates of up to 86.7% [16, 17]. However, secondary loss of efficacy has been recognised since van der Zee first reported biologic therapy failure more than a decade ago [18]. Resistance to adalimumab is now increasingly acknowledged [13] and treatment failure has also been reported in other chronic inflammatory diseases [19]. Furthermore, paradoxical HS induced by biologic agents has been described, with adalimumab responsible for nearly half of cases [20]. Discontinuation of biologic therapy usually results in clinical improvement [12], whereas temporary withdrawal often leads to recurrence or progression [21]. Severe adverse events, including life‐threatening complications, have also been reported [22]. Although newer agents such as ustekinumab show promise [23], current evidence indicates that biologic therapies are not without important limitations in advanced disease.

Several authors have highlighted the potential benefits of combining biologic therapy with surgery [24]. However, biologics may impair wound healing by suppressing the inflammatory response [24]. In contrast, correctly performed surgery removes all structures prone to relapse and is not typically associated with disease exacerbation. In our cohort, surgical excision resulted in sustained local disease control after prior adalimumab therapy had failed under institutional protocols. This observation reflects the outcomes under our specific treatment regimen and does not preclude different results with alternative biologic agents or protocols. Surgery also provides tissue for histopathological evaluation, enabling early detection of malignant transformation. As HS is now regarded as a disease of the pilosebaceous unit rather than the sweat glands [25], surgical excision can be tailored to the involved tissue, potentially reducing unnecessary tissue sacrifice and scarring [26].

Our patients presented with extensive skin defects following wide local excision. Reconstruction options vary according to defect size and location. While some authors favour secondary intention healing, particularly in the perineum where graft immobilisation is challenging [5, 25], we employed meshed STSG as a reconstructive option with favourable outcomes. Areas of poor graft take and wound margins were left to heal secondarily, which accelerated recovery and reduced immobilisation time. Although unmeshed grafts have been associated with superior cosmetic outcomes for penile skin replacement [5, 6], patients in our series reported acceptable cosmetic and functional results with meshed grafts.

Long‐term outcomes and recurrence remain critical considerations. Evidence consistently indicates that wide excision to healthy subcutaneous tissue provides the most durable local disease control, while limited excision or residual folliculopilosebaceous tissue increases relapse risk [5, 6, 7, 14, 25]. In our cohort, no recurrence was observed within surgically treated areas during a median follow‐up of 19.2 months, suggesting sustained disease remission. The absence of adnexal structures in STSG may contribute to lower recurrence compared with flap‐based reconstruction, which can preserve disease‐prone tissue [25, 27].

HS is not primarily an infectious disease but rather a hyperergic condition in which follicular occlusion triggers an innate immune response [28]. Advanced stages are typically colonised by diverse aerobic and anaerobic bacteria, consistent with our findings of polymicrobial flora in Hurley stage III patients [29]. Microbiological assessment played a key role in guiding perioperative management. Antimicrobial therapy was adjusted according to wound culture results. The timing of NPWTi‐d and STSG placement was tailored to bacterial load and pathogen identification, ensuring optimal wound healing and graft take. The identification of S. marcescens aligns with previous reports describing this pathogen in skin and soft‐tissue infections, particularly in immunocompromised individuals [30]. We also observed bacterial species not typically associated with cutaneous infections in patients previously treated with biologic therapy; however, the clinical significance of this finding remains uncertain and warrants further investigation.

Two‐stage surgical approaches for severe HS have been reported previously. Over a decade ago, Gonzaga et al. demonstrated success using dermal regeneration templates followed by STSG [31]. In our series, such matrices were not used due to cost considerations, although their advantages in wound healing are acknowledged. NPWTi‐d has also demonstrated superiority over NPWT alone by reducing bacterial load and promoting granulation [32, 33, 34]. Our experience aligns with previous reports suggesting that multistage surgery combined with NPWT and antiseptic instillation improves wound bed preparation and reduces infection risk [35].

Most patients in this series required temporary colostomy due to disease extent and infection risk. Less invasive faecal management strategies may represent an alternative in selected cases and merit further evaluation [36]. Pharmacological strategies can reduce the need for colostomy in carefully selected patients. Systemic antibiotics (clindamycin–rifampicin or tetracycline‐based) or biologics such as adalimumab may partially control inflammation and drainage, but efficacy is limited in extensive Hurley stage III disease. Patients with limited perianal involvement, no complex fistulising disease, preserved sphincter function, controlled local infection and partial response to systemic therapy are the most likely to benefit from pharmacological optimisation without colostomy, whereas temporary faecal diversion remains important in more extensive disease [8, 13, 18, 19, 20, 21, 26, 36].

While two‐stage radical excision with partial‐thickness reconstruction was employed in our series, alternative approaches exist. Single‐stage wide excision with primary closure or flap reconstruction can shorten treatment time and improve cosmetic outcomes in selected locations [25, 27]. Flap‐based reconstruction provides thicker tissue coverage but may preserve adnexal structures, potentially increasing recurrence risk [25, 27]. Healing by secondary intention is less technically demanding but requires prolonged wound care, especially in the perineum [5, 25]. Comparative data suggest that recurrence rates are generally lowest following wide radical excision, whereas functional and cosmetic outcomes vary with technique and defect location, allowing surgeons to tailor management to disease extent, anatomy and anticipated outcomes [5, 6, 14, 25, 27].

5. Conclusion

In this retrospective case series, two‐stage radical surgical excision of the affected tissue followed by reconstruction without full‐thickness skin layers may represent a promising treatment approach for patients with severe HS. In our series, this method achieved complete disease remission within the treated areas during the follow‐up period, with no observed recurrence.

These findings suggest that such a surgical strategy may offer advantages over biologic therapy, which, although effective in selected severe cases, lacks curative potential due to residual tissue structures prone to relapse. Moreover, disease progression can occur despite biologic treatment, leading to more advanced stages.

We therefore encourage further research on this therapeutic approach, which we plan to continue applying in the surgical management of patients with this condition.

6. Limitations

This study is limited by its retrospective design, small sample size and single‐centre setting, which are inherent to case series and restrict the generalisability of the findings. The absence of a control group precludes direct comparison with alternative treatment strategies. The cohort was highly selected and comprised exclusively male patients with advanced Hurley stage III disease requiring complex multistage reconstruction, which may further limit extrapolation of these findings to patients with less extensive disease, female patients or those managed with less invasive surgical approaches. In addition, functional and quality‐of‐life outcomes were not assessed using validated instruments. Although the median follow‐up was 19.2 months, longer observation is warranted, as late recurrence in HS has been reported.

Funding

The authors have nothing to report.

Ethics Statement

The study was exempt from formal approval by the local ethics committee, as it involved a retrospective analysis without direct patient intervention. Written informed consent was obtained from all patients for participation and for the publication of anonymised clinical data and images.

Conflicts of Interest

The authors declare no conflicts of interest.

Fuchs N., Pavljak L., Hauptman D., and Mance M., “Two‐Stage Surgical Management of Anogenital Hidradenitis Suppurativa in Patients on Biologic Therapy: A Retrospective Case Series,” International Wound Journal 23, no. 4 (2026): e70874, 10.1111/iwj.70874.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.