HS is a debilitating disease that significantly impairs patients’ quality of life. Unlike other chronic inflammatory dermatoses such as psoriasis or atopic dermatitis, HS frequently results in irreversible structural damage which necessitates surgical intervention [1]. When such lesions appear, surgery becomes an essential therapeutic modality to complement medical management [3, 4]. Recent evidence highlights that combining surgery with biologic therapy improves clinical outcomes and patient satisfaction more effectively than either approach alone. Notably, a phase 4 trial in 206 patients with Hurley stage III HS demonstrated that adalimumab improved HiSCR rates post surgery without increasing complications [1, 2]. Moreover, surgery has been shown to significantly enhance patients’ quality of life, activity levels, and sexual health, reinforcing its central role in the management of HS [3].

This study presents one of the largest single-centre surgical series in HS to date, comprising 206 procedures, with a focus on surgical recurrence. Our findings support wide excision followed by modified secondary intention healing, and specifically the SWC technique, as a safe and effective strategy. The overall complication rate was 11%, which is comparable or lower than those reported in the literature. For instance, Tang et al. (2023) reported a 22.1% complication rate, mainly wound infections [4], Fertitta et al. (2020) reported 10% [20] and Chang et al. (2024) reported 35.9%, with dehiscence being the most common [5].

In addition to its safety profile, SWC also yielded a reduced mean healing time of 46.4 days. This is notably shorter than that reported in similar studies. For example, Ezanno et al. (2024) observed a mean of 74 days [6] and Allison (2022) described healing times of 9.6 weeks [7]. Our results are comparable to those of Ravi et al. (2022), who reported a healing time of 4–5 weeks [8]. These differences may reflect the unique features of the SWC technique, which allows for pseudo-primary closure during the early postoperative period, promoting progressive wound reduction and enhancing patient comfort [9].

The longer healing times observed in patients receiving adalimumab are likely multifactorial. First, confounding by indication must be considered, as patients treated with biologics generally presented with more severe or highly inflammatory disease, which itself may prolong postoperative recovery. Additionally, the immunomodulatory effects of tumour necrosis factor alpha (TNFα) inhibition can alter the inflammatory and proliferative phases of wound repair, potentially delaying early tissue regeneration. Together, these factors provide a plausible explanation for the extended healing times in this subgroup and highlight the complexity of interpreting postoperative outcomes in patients with advanced systemic therapy [2].

The overall recurrence rate in our series was 18.5%, which falls within the range reported in previous studies (Table 3). Although some studies report lower recurrence rates, many do not specify the duration of follow-up, making comparisons difficult [10,11,12]. When tunnel recurrence is considered independently, a lower rate is observed (8.3%), which is below most reported rates for wide excision. More importantly, tunnel recurrence appears to be a more specific and clinically meaningful indicator of surgical failure. This is because the primary objective of wide excision is the removal of chronic structural lesions, such as tunnels. In contrast, AN recurrence may reflect ongoing inflammatory activity or insufficient medical control rather than surgical inadequacy. In this context, our stratified analysis showed that patients not receiving systemic therapy at the time of surgery had higher recurrence rates, while the trends observed with biologic and antibiotic therapy likely reflect underlying disease severity and the impact of perioperative inflammatory control. Although these associations should be interpreted cautiously, they reinforce the importance of optimising medical management around surgery to minimize postoperative recurrence. Therefore, we propose that tunnel recurrence should be prioritized as the primary outcome measure when evaluating the long-term effectiveness of surgical treatment in HS.

In this context, identifying strategies to minimize true surgical failure becomes essential. Although preoperative ultrasound was associated with lower recurrence rates in our cohort, the retrospective design of this study precludes establishing a causal relationship. The observed association may simply reflect more accurate delineation of subclinical disease rather than a direct protective effect of ultrasound itself; therefore, any causal inference remains speculative and should be confirmed in prospective controlled studies. Nonetheless, several mechanisms provide biological plausibility for a beneficial effect. Ultrasound enables the identification of subclinical tunnels and deep tract extensions that are frequently underestimated on physical examination, improving the completeness of excision and thereby potentially reducing tunnel-type recurrence. It also detects deep inflammatory nodules and early abscesses that may not be clinically evident, allowing more comprehensive removal of active inflammatory foci and potentially reducing AN-type recurrence. This mechanistic rationale aligns with the trends observed in our cohort and with emerging evidence suggesting that ultrasound-guided surgical planning may have an even greater impact on reducing recurrence than preoperative biologic therapy [13].

Differentiating tunnel from AN recurrence may have important clinical implications. Tunnel recurrence is more likely to require reintervention, given its structural nature and its association with incomplete excision. In contrast, AN recurrence might be better addressed with medical intensification, particularly in patients with ongoing systemic inflammation. Recognizing this distinction could improve patient stratification, surgical decision-making and postoperative management strategies [2].

This study has several limitations. First, it is an observational, single-centre study, which may limit the generalizability of results. Second, although our cohort is substantial, the subgroup of patients experiencing surgical recurrence remains relatively small, potentially limiting statistical power. Third, postoperative medical management—particularly the use and adjustment of systemic therapies—was not fully standardised, which may have influenced postoperative inflammatory control and contributed to the frequency of AN-type recurrences. Finally, the heterogeneity in surgical techniques and definitions of recurrence across the literature complicates direct comparison with other studies.