HS Surgery: De-Roofing Alongside Biologic Therapy

"HS Surgery: De-Roofing Alongside Biologic Therapy" takes up the question of how procedures fit into HS care alongside advanced therapy.

The panel is asked how it views surgical procedures such as de-roofing and whether they help with pain, drainage, and quality of life. The panel describes disease management as two parallel tracks. Medical management includes counseling and escalation to biologics or oral small molecules, while surgical intervention can run alongside it. The surgical conversation should be raised at every follow-up visit, particularly when draining tunnels or localized inflammation could be controlled by a de-roofing procedure. The panel notes that data now support performing these procedures, and even larger surgeries, while patients remain on therapy. For a time, whether to take patients on and off their biologic around surgery was a major open question. The paradigm has shifted to treating on drug, which has improved outcomes because inflammation stays controlled while the patient heals. Remaining on biologics throughout is considered safe and probably better for healing, with no breaks needed.

For listeners who do not perform de-roofing, the panel emphasizes that it requires little time or equipment. It requires willingness, and procedures can be as small or as extensive as a clinician is comfortable with, always within scope of practice. Anyone who can perform an excision or electrodessication and curettage can de-roof, because the tools and tissue planes are the same. Clinicians can stop and ask for help if they reach an area outside their comfort zone. For larger operations, regional HS surgery experts and referral centers can perform graft placements, while smaller de-roofings are handled in the department.

The panel also covers coding. De-roofing uses the same CPT codes as certain plastic surgery procedures, which are limited to three anatomic areas: axilla, inguinal region, and buttocks. For the chest or back, clinicians approximate the closest area.

Our next episode, "HS Biologics: IL-17 vs TNF Inhibition, Bimekizumab Tunnel Data, and Early Treatment," turns to how TNF and IL-17 inhibitors differ and what newly presented tunnel data suggest.