Hidradenitis Suppurativa Wound Care: Treatment Approach

Hidradenitis Suppurativa Wound Care: A Clinical Guide

Hidradenitis suppurativa (HS) is a chronic, recurrent inflammatory skin disease affecting the apocrine gland-bearing areas of the body — axillae, groin, inframammary folds, perianal and perineal regions, and buttocks. For wound care clinicians, HS presents a dual challenge: managing actively draining, painful wounds while coordinating with dermatology on the systemic disease that drives recurrence. Effective hidradenitis suppurativa wound care requires understanding the disease staging, knowing when local wound management is sufficient, and recognizing when surgical referral is indicated.

HS affects an estimated 1% to 4% of the population, with onset typically between puberty and age 40. It is more common in women and is associated with obesity, smoking, and metabolic syndrome. Many patients live with HS for years before receiving a correct diagnosis, meaning wound care clinicians may be the first providers to recognize the pattern.

Hurley Staging and Wound Care Implications

The Hurley staging system classifies HS severity into three stages. Each stage carries different wound care priorities.

Hurley Stage I — Abscess Formation

Single or multiple isolated abscesses without sinus tracts or scarring. Lesions may be recurrent but occur in separate episodes.

Wound care role: Limited. Stage I is primarily managed medically by dermatology. Wound care clinicians may encounter Stage I patients incidentally and should recognize the pattern to facilitate referral. If an abscess has been incised and drained (I&D), standard post-I&D wound care applies — packing with iodoform gauze or alginate, daily dressing changes until the cavity granulates closed.

Hurley Stage II — Sinus Tract Formation

Recurrent abscesses with sinus tract formation and scarring. Widely separated lesions with intervening normal skin.

Wound care role: Active. Stage II patients frequently need ongoing wound management for draining sinus tracts. Key considerations:

Sinus tracts produce continuous serous or purulent drainage
Perilesional skin is at high risk for maceration and contact dermatitis
Pain management is a significant component of care
Lesions may flare and remit independent of wound care interventions

Hurley Stage III — Diffuse Involvement

Diffuse or near-diffuse involvement across an entire anatomical region with multiple interconnected sinus tracts and abscesses. Extensive scarring.

Wound care role: Active and often intensive. Stage III patients may require daily dressing changes, significant pain management, and coordination with surgical planning. Post-operative wound care after wide excision is a primary wound care function.

Dressing Selection for HS Wounds

HS wound dressing must address three simultaneous challenges: high exudate volume, anatomical location in skin folds, and extreme tenderness.

Primary Dressings

Hydrofiber or alginate for heavily draining sinus tracts — provides absorption without adhering to the wound base
Silicone contact layers (Mepitel) as a primary layer under absorbent secondary dressings for tender wounds
Antimicrobial dressings (silver or PHMB-containing) when clinical signs of secondary infection are present — not for routine use, as HS drainage is inflammatory rather than infectious in most cases

Secondary Dressings

Absorbent foam pads secured with tubular netting or soft silicone tape
Abdominal pads for high-volume drainage in axillary or inguinal locations
Avoid adhesive borders in areas of active disease — the skin is too fragile and inflamed

Fixation

Anatomical locations (axillae, groin, inframammary) make dressing fixation difficult:

Tubular elastic netting (Surgilast, Spandage) is the most practical fixation method
Underwear or compression garments can hold inguinal and perineal dressings in place
Silicone tape (Mepitac) for supplemental fixation where needed
Avoid circumferential wrapping that restricts range of motion

Wound Care vs. Disease Management

A critical distinction for wound care clinicians treating HS: local wound care does not treat the underlying disease. HS is driven by follicular occlusion and aberrant immune response. Without systemic disease management, wounds will recur regardless of how well the current wounds are managed.

The wound care clinician's responsibility includes:

Managing the active wounds — drainage control, perilesional skin protection, pain management
Ensuring the patient has an active dermatology relationship — systemic therapy (biologics such as adalimumab or secukinumab, antibiotics, retinoids) is the domain of dermatology
Communicating wound trajectory to the dermatologist — worsening despite medical therapy may indicate the need to escalate treatment or consider surgery
Not over-treating wounds as infected — HS drainage is inflammatory. Routine wound cultures from HS sinus tracts grow normal skin flora or are polymicrobial. Systemic antibiotics for HS are prescribed for their anti-inflammatory properties by dermatology, not in response to wound cultures.

For more on building effective dermatology referral relationships for complex wound patients, see Wound Care and Dermatology Partnership.

Surgical Referral Triggers

Surgery is the definitive treatment for Hurley Stage II and III disease that fails medical management. Wound care clinicians should recommend surgical evaluation when:

Sinus tracts persist despite >3 months of optimized medical therapy
Recurrence in the same anatomical area occurs within weeks of wound closure
Stage III diffuse involvement with interconnected tracts — medical therapy alone rarely achieves durable remission
Functional limitation — axillary involvement restricting arm movement, inguinal involvement affecting ambulation
Malignant transformation concern — rare but documented, SCC can develop in chronic HS wounds (particularly perianal)

Surgical approaches for HS include:

Wide local excision with healing by secondary intention or skin grafting — highest cure rate for the excised area
Deroofing of individual sinus tracts — less extensive, faster recovery, suitable for isolated Stage II tracts
Laser ablation (CO2 or Nd:YAG) — emerging evidence for Stage I-II disease

Post-surgical wound care is where wound care clinicians add the most value. Wide excision sites can be large (10 cm × 15 cm or greater in axillary or inguinal regions) and require weeks to months of wound management as they granulate and contract.

Pain Management and Quality of Life

HS pain is frequently undertreated. The wounds are located in areas of constant friction and movement. Clinicians should:

Assess pain at every visit using a validated scale
Use topical lidocaine before dressing changes
Advocate for adequate systemic analgesia — HS wound pain is legitimate and often severe
Screen for depression and anxiety, which are highly prevalent in HS patients
Refer to support resources (HS Foundation, patient support groups)

For a comprehensive approach to wound-related chronic pain, see Chronic Pain Management in Wound Care.

Key Takeaways

Hidradenitis suppurativa is a chronic inflammatory disease, not an infection — routine wound cultures and empiric antibiotics are not appropriate for standard HS drainage.
Hurley staging (I, II, III) determines the wound care clinician's level of involvement, from minimal in Stage I to intensive in Stage III.
Dressing selection must prioritize high absorption, non-adherence, and creative fixation for difficult anatomical locations.
Surgical referral is indicated when sinus tracts persist despite >3 months of optimized medical therapy or when Stage III disease causes functional limitation.
Every HS patient managed by wound care must have an active dermatology relationship for systemic disease management — local wound care alone does not control the underlying disease.