Closure strategies following wide excision for hidradenitis suppurativa: a systematic review across primary closure, secondary intention, skin grafting, and flaps

Abstract

This systematic review evaluates outcomes of closure strategies following wide or radical excision for hidradenitis suppurativa (HS), comparing primary closure, secondary intention healing (SIH), split-thickness skin grafts (STSG), and local/regional flaps. A systematic search of PubMed/MEDLINE, Scopus, and Google Scholar was conducted up to September 2025. Studies reporting site-specific recurrence, complications, time to healing, functional recovery, or patient-reported outcomes (PROs) after wide excision for HS were included. Study quality was assessed using JBI checklists and SANRA. Thirty-one studies were included. Wide excision was consistently associated with lower recurrence than limited excision. Following adequate excision, closure modality significantly influenced outcomes. Flap reconstruction, particularly perforator flaps in the axilla, demonstrated the lowest recurrence (0–4), acceptable complications, and superior functional recovery. STSG achieved low recurrence but had higher failure and complication rates in axillary sites. SIH showed acceptable recurrence (10–12), significant PRO improvements, but longer epithelialization times. Primary closure was associated with the highest recurrence and dehiscence rates. Outcomes were highly site-dependent, with anogenital disease exhibiting higher long-term recurrence regardless of closure method. Preoperative ultrasound mapping and negative-pressure wound therapy were associated with improved outcomes. Closure strategy impacts outcomes after wide excision for HS, but effect is moderated by anatomic site. Flaps offer a favorable balance in the axilla, while SIH is a robust option across sites. Future prospective, site-stratified studies with standardized outcomes are needed to refine evidence-based algorithms. © The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2026.