Should a groin cyst be removed in a patient with hidradenitis suppurativa?

Should You Remove a Groin Cyst in Someone with Hidradenitis Suppurativa?

Yes, you should surgically remove groin lesions in hidradenitis suppurativa (HS), but the approach depends critically on whether this is an acute inflammatory lesion versus chronic disease—use deroofing for acute/subacute lesions and consider extensive excision for chronic, recurrent, or treatment-refractory disease.

Understanding What You're Dealing With

First, clarify what "groin cyst" means in the HS context. The IDSA guidelines note that recurrent abscesses should prompt evaluation for hidradenitis suppurativa as an underlying cause 1. In HS, what appears as a "cyst" is typically either:

• An acute abscess or inflammatory nodule
• A chronic sinus tract with overlying skin involvement
• Scarred, fibrotic tissue from repeated inflammation

This distinction drives your surgical approach entirely.

Acute/Subacute Lesions: Deroofing is Preferred

For acute inflammatory lesions, perform deroofing rather than simple incision and drainage. The North American guidelines emphasize that incision and drainage alone has recurrence rates approaching 100%, while deroofing shows only 4-17% recurrence 2.

The deroofing technique involves:

• Probing the abscess and associated sinus tracts
• Removing the overlying skin stepwise (with punch tool, scalpel, or electrosurgery)
• Leaving the base untreated to heal by secondary intention
• Achieving 90% patient satisfaction in case series

Simple drainage provides only temporary relief and virtually guarantees recurrence—it should only be used when deroofing isn't feasible or for very large abscesses requiring acute decompression before definitive surgery 2.

Chronic/Recurrent Disease: Extensive Excision

For chronic groin HS or disease unresponsive to medical therapy, consider extensive excision to minimize recurrence. The British Association of Dermatologists guidelines specifically recommend extensive excision when conventional systemic treatments have failed 3.

Key surgical principles:

• Excise down to the fascia with adequate margins
• Wider excision margins correlate with lower recurrence rates 4
• The groin/inguinal region has higher recurrence rates than other sites 2
• Secondary intention healing may have lower recurrence than primary closure, though healing takes longer 3, 4

For localized inguinal HS, immediate reconstruction with medial thigh lift has shown excellent results with no recurrences in small series, provided no active infection is present 5.

Medical Optimization Before Surgery

Don't operate in isolation. The British guidelines emphasize that surgery should be considered as adjuvant to medical treatment 3. Before or concurrent with surgery:

• Mild-moderate disease: Start oral tetracyclines (doxycycline/lymecycline) for at least 12 weeks 3
• Unresponsive to tetracyclines: Use clindamycin 300mg BID + rifampicin 300mg BID for 10-12 weeks 3
• Moderate-severe disease: Offer adalimumab 40mg weekly (after loading doses) 3, 4
• Consider intralesional corticosteroids for individual acute lesions 3

Critical Pitfalls to Avoid

1. Don't perform simple incision and drainage for HS lesions—this guarantees recurrence and doesn't address the underlying pathology 2

2. Don't operate on actively infected tissue without debridement first. The IDSA guidelines recommend antibiotics for systemic signs of infection (fever, tachycardia, elevated WBC) 1. One case series specifically excluded patients with clinical infection signs at surgery 5.

3. Don't forget to culture recurrent lesions early in the course and treat based on pathogen isolated 1

4. Don't ignore the need for ongoing medical management post-operatively—surgery doesn't alter disease biology, so new lesions can develop in other areas 2

Practical Algorithm

For acute groin lesion in HS patient:

• Perform deroofing (not I&D)
• Culture if recurrent
• Start/optimize systemic antibiotics
• Consider intralesional steroid

For chronic/recurrent groin HS:

• Optimize medical therapy first (antibiotics → biologics if moderate-severe)
• If medical therapy fails after 12-16 weeks → extensive excision
• Plan for secondary intention healing or delayed closure
• Continue medical therapy post-operatively

For widespread moderate-severe HS:

• Prioritize systemic therapy (adalimumab as first-line biologic) 3, 4
• Use surgery as adjunct for localized problematic areas
• Screen for comorbidities (depression, cardiovascular risk, inflammatory bowel disease) 3

The groin location makes this particularly important to get right—this area has higher recurrence rates and significant impact on quality of life and function 2. Aggressive treatment with both medical and surgical modalities gives the best chance of disease control and preventing the devastating complications of long-standing HS.