Condition & treatment
Hidradenitis suppurativa
A follicular disease that produces recurrent painful lumps, drainage and tunnels under the skin — most often in the buttocks, groin, perianal region and armpits. It is commonly mistaken for something else for years before it is named.
If this has been called something else
Most people with hidradenitis are treated for something else first. In this region in particular, four conditions account for most of the confusion — and more than one of them can be present at the same time.
A recurrent abscess
Drained again and again, in the same place. A boil that keeps coming back in the same spot is one of the most common ways HS is missed.
An anal fistula
Cryptoglandular fistula and perianal HS can look and behave alike. They are treated differently, and they can occur in the same patient.
A pilonidal cyst
Gluteal HS sits in the same territory. Pilonidal disease and HS can look identical, and can coexist — which is why one failing to settle is worth a second look.
Crohn's perianal disease
Another condition that produces tracts and drainage in this region, and another reason the first job of a consult is confirming which disease is present.
The first job of a consultation is confirming which disease is actually present. Treating HS as a fistula, or a fistula as HS, is how people end up years into the wrong plan.
Two diseases in sequence
Hidradenitis behaves as an inflammatory disease first and a structural one second, and the distinction decides the treatment.
Inflammatory
It starts at the follicle
The follicle opening becomes occluded, the follicle ruptures into the surrounding tissue, and the immune response produces the nodules and abscesses you feel. Drainage, scarring and tunnels all follow from that first event.
Structural
Then it becomes a tunnel
A sinus tract is not inflamed tissue — it is a channel lined with skin-like cells. Antibiotics do not close it and biologics do not close it. Left alone, tracts drain intermittently, recruit nearby follicles, and join up over time.
Two lasers, one for each stage
Laser 1 · 1064 nm · Cynosure Elite iQ
Follicle-directed therapy
A long-pulsed Nd:YAG laser reduces the follicular population in the affected region, taking fuel away from the disease. Sessions run 20–45 minutes depending on area, need no anesthesia, and you drive yourself home and return to normal activity the same day. The work is the four-to-six-month course, not the recovery from any one session.
Laser 2 · 1470 nm
Intralesional tunnel closure
A thin radial fibre is passed into each accessible tract through an opening it already has, then withdrawn slowly while treating the lining, so the tract collapses and closes. No skin incision, no excision, no open wound to pack. Done in the office under local anesthetic, with a pressure dressing for 24–48 hours and desk work the next day.
This is the same intralesional laser technique used in the practice's pilonidal laser program — applied to hidradenitis tracts rather than a pilonidal sinus.
Where this sits in HS care
Hidradenitis is not one specialty's responsibility, and most patients will sit on several rungs of this ladder over the course of the disease. Laser treatment is the procedural tier between medical therapy and excisional surgery — it does not replace either.
- 01Lifestyle and topical carePatient + primary careSmoking cessation, weight management where relevant, gentle antiseptic washes, friction reduction. A foundation, not a treatment on its own.
- 02Systemic medical therapyDermatology / rheumatologyOral antibiotics for their anti-inflammatory effect, hormonal modulation, and biologic agents such as adalimumab and secukinumab. The medical arm of HS control.
- 03Follicle-directed laser therapyHereLong-pulsed sessions that reduce the follicular population driving inflammation — the procedural answer to active disease.
- 041470 nm intralesional tunnel closureHereA thin radial fibre is passed through an existing tract opening and withdrawn while coagulating the lining. No skin incision.
- 05Wide excision and reconstructionReconstructive surgeryFor disease too extensive or too scarred for a tract-directed approach. Effective, and a much larger undertaking.
Perianal and gluteal disease
Disease around the anus and in the buttock crease is its own conversation. The anatomy is dense — sphincter, anal canal, gluteal cleft — and any operative plan has to protect continence, a concern that simply does not arise for disease in the armpit. That is the reason a colon and rectal surgeon is the relevant specialist for hidradenitis in this region.
It is also the region where the differential matters most, because the conditions HS is confused with all live here too. Mapping the disease carefully, and confirming what is actually being treated, is most of the work before any laser is switched on.
Hurley staging, in plain language
Staging is a clinical determination, not a self-diagnosis — but it is the vocabulary the consultation will use, so it helps to arrive knowing it.
Hurley I
Isolated painful nodules and abscesses. No sinus tracts, no scarring between lesions.
Often misread as boils, ingrown hairs or cysts.
Follicle-directed laser is the primary tool. The goal is fewer flares.
Hurley II
Recurrent lesions with tract formation and scarring, still separated by normal skin.
The point where the disease stops being only inflammatory and becomes structural too.
Usually both lasers — follicle therapy for the active disease, tunnel closure for the established tracts.
Hurley III
Diffuse involvement, with multiple interconnected tracts across a region.
The stage where a tract-directed approach may not be enough on its own.
Assessed case by case. Some regions are treatable; some are better served by excisional reconstruction.
Training and credentials
The device
Certificate from the Institute of Aesthetic Training for completing Cynosure Elite iQ training, 29 August 2026 — the platform used for the follicle-directed sessions. That is training on a laser system, not a specialty qualification in hidradenitis.
The clinical credential
Board certification in Colon & Rectal Surgery and in General Surgery, and an established intralesional laser program — the technique the tunnel-closure procedure is drawn from. For disease next to the anal canal, that is the credential that matters.
What we are not claiming
- No outcome figures. This is a newly established part of the practice. There is no case series, no success rate and no cure rate to quote for hidradenitis, and none will appear here until there is real data to report.
- No cure. Hidradenitis is chronic. The goals are fewer and less severe flares, closure of existing tracts, and avoiding a larger operation.
- Not every case is suitable. Extensive or heavily scarred disease may be better served by excisional reconstruction, and saying so is part of the consultation.
The evidence for follicle-directed Nd:YAG therapy in hidradenitis comes from published randomised trials, including Tierney E, Mahmoud BH, Hexsel C, Ozog D, Hamzavi I. “Randomized control trial for the treatment of hidradenitis suppurativa with a neodymium-doped yttrium aluminium garnet laser.” Dermatologic Surgery 35(8):1188–98 (2009). A fuller annotated reference list, with its limits named, is on hslaserexpert.com.
Frequently asked questions
Is hidradenitis suppurativa the same thing as a pilonidal cyst?
Do I have to stop seeing my dermatologist?
Why does a colorectal surgeon treat hidradenitis?
Is the treatment done in the operating room?
Will this cure my hidradenitis?
Talk it through
A consultation starts by confirming the diagnosis and mapping what is actually there. If laser treatment is not the right answer, that is a useful outcome of the visit too.
More detail on the protocol, candidacy and evidence: hslaserexpert.com