Surgical Deroofing for Hidradenitis Suppurativa
Hidradenitis suppurativa can present in varying degrees of severity; management often poses a challenge for primary care physicians and dermatologists. Deroofing is a surgical technique that has shown superiority over standard excision. We describe the deroofing procedure and review clinical data to provide instruction and support its use.
Practice Implications
A deroofing procedure has many benefits compared to other surgical modalities for the treatment of HS. Deroofing requires only a probe, curette, and electrocautery device, making the procedure more cost-effective than excision, which requires a full tray of equipment and sutures. Furthermore, margins do not need to be taken with deroofing, and no undermining or closure is needed, which saves time during the operation and minimizes the risk for complications, including dehiscence and formation of new sinus tracts.4 No specialized equipment, such as a CO2 laser, is required, which makes deroofing accessible to every clinical dermatologist in any demographic or geographic setting.
Evidence of Benefit—Saylor and colleagues5 found that deroofing carries a 12.5% complication rate, which includes postoperative bleeding, hypergranulation tissue, and rarely wound infection. This rate is significantly lower than the 26% complication rate associated with local excision, which includes wound dehiscence, infection, and contracture (P<.001). Deroofing also was found to have an HS recurrence rate of 14.5%, which is significantly less than the 30% recurrence rate seen with local excision (P=.015). Saylor et al5 also concluded that incision and drainage was recommended only for immediate relief of HS because of its 100% recurrence rate.
van der Zee2 reported on 88 lesions from 44 patients that were treated by surgical deroofing, resulting in an average defect of 3.0 cm in length and a mean healing time of 14 days. The typical outcome was cosmetically acceptable scarring; this finding was supported by a postoperative survey (>1 year), to which 37 of 44 patients responded and assigned an average satisfaction score of 8 (of a possible 10) and a recommendation rate of 90%.2
Procedural Coding—Specific Current Procedural Terminology codes (11450-11471) from the International Classification of Diseases, Tenth Revision, exist for HS deroofing procedures; the applicable code for a given case depends on the final length of the surgical defect. Documentation to support these codes is similar to the note for an excision procedure, taking care to include location, depth, and length of the excision; healing by secondary intention; and the diagnosis of HS.
Final Thoughts
Deroofing is a surgical option that can be beneficial to patients with HS. It is a relatively simple procedure available to any dermatologist, regardless of setting. We encourage dermatologists to consider deroofing, even in patients with Hurley stage II lesions, because it can yield cosmetically acceptable and definitive results, given the variety of therapies available for HS. Deroofing also can be superior to standard excision, especially because of the potential complications with standard excision and quicker operative time with deroofing. As more providers become familiar with the deroofing procedure for HS, further studies can be undertaken to add to the paucity of data about deroofing and how it compares to other surgical treatments.
