The pathogenesis of HS includes epithelial hyperplasia of the ductal isthmus resulting in follicular hyperkeratosis, occlusion, and expansion. [9,10]. Friction and pressure on the skin cause molecular-sized antigen leakage, which stimulates the innate and adaptive immune system [1]. Consequently, cytokines are released which causes keratinocyte-induced activation of proinflammatory mediators [11,12]. If cellular damage is extensive then rupture of the follicular duct occurs precipitating the release of macro-follicular contents such as keratin fragments, sebum, and bacteria [1]. Prolonged response evolves into a chronic foreign body-type granulomatous inflammation [9].

HS presents as painful nodules in the intertriginous areas which progress to abscess formation and sinus tract development [2,8]. These sinus tracts become inflamed and drain seropurulent discharge. The late stage of HS presents with open or closed comedones and scarring after resolution which can range from fibrotic, rope-like bands to indurated, thick, scarred plaques causing disfigurement [1,10]. In this case, both patients had sinus tract formation and scarring. The diagnosis of HS is clinical and can often be misdiagnosed therefore a full skin examination is important [6].

HS is managed either conservatively, medically, or surgically and the Hurley staging system, which stratifies HS into three categories, is utilized [12]. Stage I is characterized by abscess formation only. Stage II is identified by recurrent abscesses with skin tunneling, scarring, and widely separated lesions. Stage III is marked by diffuse involvement of multiple connected skin tunnels and abscesses [1]. Lifestyle changes such as weight reduction, smoking cessation, and wound management are essential to implement. Antibiotics are the first-line medical therapy for Stage I or mild Stage II lesions and include topical agents such as Clindamycin [1].  Systemic agents like Clindamycin-Rifampicin and Rifampicin-Moxiflocacin-Metronidazole are required for severe lesions [6]. Finally, Adalimumab is effective in treating moderate to severe HS [12].

In severe, refractory HS, surgical intervention with punch debridement, unroofing, incision and drainage, or wide excision is indicated. Punch debridement involves the removal of the affected Follicular Pile Sebaceous Unit (FPSU) and its associated glands in one punch [11]. In a study where eleven patients received this procedure, only three had a recurrence, inferring adequate efficacy [11] Unroofing is beneficial for Stage III lesions and consists of the removal of the fibrotic skin with debridement of excess tissue, abscesses, and sinus tracts [12]. The wound is left open, allowing it to heal by secondary intention [6]. Incision and drainage is associated with a high disease recurrence rate since the underlying etiologies are not addressed [13]. Finally, wide excision is the ideal treatment of severe Stage II or III lesions and involves the removal of the entire affected area with margins beyond the clinical borders [1,12]. It is associated with longer healing times and a longer period of remission [14].

In a cohort study, 27 patients with a 7-year history of moderate to severe HS in multiple regions were treated by surgical excision [8]. Most patients were previously treated with non-surgical methods such as short-term antibiotic therapy and local wound care. 19 months after surgical intervention with wide excision coupled with graft placement, there were only two reports of recurrence [8]. Another study included 102 patients with Hurley stages I (13.5%), II (53.1%), and III (33.3%) HS who were treated with systemic antibiotics (88.2%), surgery (67.6%), antibiotic topical therapies (55.9%), and biologics (11.8%). The study reported that while antibiotics were more commonly used, surgery was the most effective treatment strategy [15]. These studies infer those conservative methods of treatment have a negligible effect on moderate to severe HS and surgical methods, specifically wide excision is preferred.

The patients in our study had Stage II and III HS and were managed with wide excision. After surgery, both patients reported improvement in their pain and their wounds showed considerable granulation tissue formation on follow-up. HS should be considered in any person with intertriginous nodules, skin tunnels, or abscesses and positive risk factors. Wide excision is the gold standard surgical procedure and is associated with decreased recurrence rates. It allows normal tissue regeneration and improves patients’ quality of life.