Several surgical treatment options are available for HS, including unroofing, also known as deroofing. This technique involves removing all tissue affected by HS, right down to the tunnels beneath the skin.

People exploring surgical options for HS may want to know more about this technique, as it can sometimes be performed in an outpatient setting. It has also been shown to have a lower recurrence rate than excision, another surgical procedure commonly used to treat HS.

To learn more about this procedure, myHSteam talked with Dr. Hadar Lev-Tov, assistant professor and board-certified dermatologist at the University of Miami Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery.

What Is HS?

Hidradenitis suppurativa (HS) is a chronic skin disease that causes painful lumps to form beneath the skin. These lesions result from the abnormal blockage of hair follicles, leading to an immune system response that causes inflammation and swelling.

The main affected areas in HS are those where skin friction occurs. This makes the armpits, breasts, buttocks, inner thighs, and groin prime targets. These areas also have the most apocrine sweat glands, which are located in areas of the body with high concentrations of hair follicles.

What Is Unroofing?

In unroofing, a doctor removes the lesions and tunnels caused by HS beneath a person's skin. This is done by inserting a probe into the tunnel, cutting the top of it, and removing the entire tunnel, along with the skin that acts as a roof above it.

"The idea of deroofing is to give you the benefit of a surgical procedure without requiring the entire operation of numbing up an entire large area and making a big wound," Dr. Lev-Tov said. "It is not a definitive treatment for the entire disease, it's just to try to solve a problem with one tunnel at a time."

When Is Unroofing Appropriate, and Where?

According to the Mayo Clinic, unroofing is appropriate for those with moderate to severe hidradenitis suppurativa. It is also recommended for people with recurring HS flare-ups in the same area of skin.

Some people may wonder if this treatment for hidradenitis suppurativa is more effective on certain parts of the body than others. Dr. Lev-Tov said that while there is no definitive answer to this question, he has seen the most success in his practice when the underarm is treated with deroofing.

"I don't know that there's clear evidence on what site is better," he said. "But I would say that in my anecdotal experience, whenever you have axillary disease, meaning of the armpits, it tends to work better in general."

He explained that this is likely because the armpit is easier for people to care for and because it experiences less friction than other parts of the body.

Will Unroofing Work? What Are the Risks?

The effectiveness of unroofing has been the subject of multiple studies, many of which have found it to be a good medical treatment option. In May 2020, the journal Dermatology and Therapy reviewed 55 articles focusing on surgical techniques for HS, including unroofing.

Results showed that recurrence rates in people who underwent unroofing were 14.5 percent, compared with 30 percent for excision — removal of larger areas of affected skin. In terms of people who experienced complications after treatment, only 12 percent of people who had undergone unroofing experienced problems after surgery, as opposed to 26 percent for those who had undergone excision.

People who may be interested in the unroofing procedure should be aware that it carries a risk of leaving significant scar tissue as a side effect. There are techniques to help prevent or reduce scarring.

What Should You Expect Before and After Unroofing?

Before unroofing, health care providers may wish to give the person they’re treating a course of biologic treatments. These medications, produced using biotechnology, can reduce inflammation and lesion size, which can lead to better post-surgical outcomes. Dr. Lev-Tov gave the example of Humira (adalimumab) as a biologic that may be prescribed for HS unroofing surgery.

After unroofing, the wound is left to heal without suturing or other surgical closure. This makes it less likely that HS lesions will return in the area. Dr. Lev-Tov said that allowing the wound to heal in this way is a good option for people who have undergone unroofing, but he offered one caveat.

“It's more about the time to healing and the risk of infection,” he said. “It can take a few months until it heals.”

What Do myHSteam Members Say About Unroofing?

Some members of myHSteam have undergone unroofing and described their experiences with the procedure.

“I had this procedure done many years ago,” one myHSteam member said. “One on my left armpit and on the back of my neck. I still get cysts under my arm, but in different places than where the surgery took place.”

Another member said that she had experienced a good outcome from a combination of surgical techniques.

“I would recommend having the deroofing and [wide surgical excision] if you haven't already,” she said. “It's been two years since I had the surgery, and I haven't had any flare-ups or complications.”

Another member said that deroofing is worth exploring for its marked effect on quality of life.

“It’s best to treat it early and get surgery, or possibly deroofing, early on to help save skin,” she said. “It sucks to go through surgery, but after I had it, I was pretty much in remission for years.”

You Are Not Alone With Hidradenitis Suppurativa

By joining myHSteam, the social network and online community for those living with hidradenitis suppurativa, you gain a support group of more than 18,000 people who understand what it's like to consider surgical options such as unroofing for HS.

Have you undergone unroofing for HS? Are you weighing different surgical options? Share your experiences in a comment below, or start a conversation by posting on your myHSteam Activities page.