The framework
Three things decide candidacy
Hurley stage
Where the disease is on the inflammatory-to-structural spectrum.
Anatomic distribution
Which regions are involved and how the operative field reads.
Treatment history
What has already been tried medically and surgically, and how it went.
Self-stage
Hurley I, II, and III in plain language
Use this for orientation only. Staging is a clinical determination — the cards below help you arrive at the consult with shared vocabulary, not a diagnosis.
Isolated nodules and abscesses. No sinus tracts and no scarring between lesions.
- What it looks like
- Recurrent painful bumps, often misread as boils, ingrown hairs, or cysts.
- Typical fit
- Follicle-directed laser is the primary tool. Goal is to reduce flare frequency and slow progression before tracts form.
Recurrent abscesses with one or more discrete sinus tracts and scarring. Lesions are separated by normal skin.
- What it looks like
- Drainage from one or two specific sites; palpable cords under the skin.
- Typical fit
- Most common candidacy profile. CO₂ tunnel closure for the established tracts, often combined with follicle therapy for the surrounding inflammatory field.
Diffuse or near-diffuse involvement with multiple interconnected tracts across an entire region.
- What it looks like
- Persistent drainage, chronic pain, dense scarring across the whole area.
- Typical fit
- CO₂ tunnel closure is the primary tool, frequently staged across multiple operative encounters. Candidacy depends on regional distribution and overall health.
Not sure where you fall? Most patients who reach out are Hurley II. If you have palpable cords or drainage from a consistent site, that is a strong clue.
Anatomic fit
Region by region
| Region | Fit & notes |
|---|---|
| Axilla | Strong fit for both procedures. Well-tolerated operative field; recovery is generally the most predictable of the regions. |
| Inguinal / groin | Strong fit. CO₂ closure is well-established here. Wound care is more demanding than the axilla; positioning and clothing are part of recovery planning. |
| Gluteal | Fit, with higher recovery burden. Large wounds, sitting and hygiene logistics, longer secondary-intention healing. Worth doing — worth knowing the burden up front. |
| Perianal | Fit, with anatomic care. Proximity to the sphincter and anal canal requires a colorectal-surgical eye. Mapping is more deliberate here. |
| Inframammary / submammary | Fit for both procedures. Treatment plan accounts for skin folds and chafing during recovery. |
Good-fit signals
Patients we are well-suited to help
- An established HS diagnosis — either dermatology-confirmed or with a presentation we can confidently confirm at consult.
- A real trial of medical therapy already underway or completed, even if partial.
- Willingness to commit to a multi-session course (follicle therapy) or to healing by secondary intention (CO₂ closure).
- Ability to travel to Beverly Hills for in-person evaluation and at least one operative encounter.
- A working relationship with a dermatologist, or openness to establishing one for co-management.
Where we say no, or not yet
Reasons we may defer or decline
These are honest, not punitive. The point is to align before a procedure, not after.
- Active flare requiring antibiotics or drainage
- We let the acute episode quiet first. Operating into an active flare is poor practice.
- Medical therapy not yet given a fair turn
- If a dermatologic regimen has not been tried, we usually want that to lead. Laser is not a shortcut around medical optimization.
- Pregnancy
- Elective procedures are deferred. We are happy to consult and plan for after delivery.
- Uncontrolled comorbidities
- Diabetes that is not under control, untreated cardiac disease, active substance misuse — these affect healing and anesthesia. We address them first, with the relevant specialists.
- Smoking
- Smoking measurably worsens HS and slows wound healing. We do not refuse to treat smokers, but we will discuss it candidly and may recommend cessation support before larger operations.
- Unrealistic expectations
- If a patient is seeking a one-time cure, or believes laser will replace medical therapy, the consult is the place to align — or to part ways honestly.
- Geographic inability to attend follow-up
- Both procedures require at least one follow-up. If neither in-person nor structured remote follow-up is workable, we say so up front.
The consult
What only the consult can decide
A website cannot stage your disease, map your tracts, or choose your anesthesia. These are the questions an in-person or structured remote evaluation answers.
- True Hurley stage on examination — not by self-report.
- Tunnel mapping: which tracts exist, where they connect, and what the operative field actually looks like.
- Procedure selection: follicle therapy, CO₂ closure, both in sequence, or neither.
- Anesthesia plan: local, monitored, or general — driven by extent and patient factors.
- Sequencing across regions if more than one is involved.
Bring with you
What to prepare for the consult
- Prior imaging (ultrasound, MRI) if any has been done.
- Biopsy or pathology reports, if obtained.
- A current medication list, including biologics and any antibiotic courses in the last 12 months.
- Photographs of the affected areas — both during active flare and at rest, if possible.
- A short written history of prior procedures (incision and drainage, deroofing, excision) and their outcomes.
Insurance coverage and self-pay options are reviewed at the consult. See pricing for the posture and ranges.
Common questions
Frequently asked
- Is the candidacy on this page final?
- No. This page is orientation. True staging, tunnel mapping, and procedure planning are clinical decisions made in person with imaging, exam, and history.
- Why might you decline a patient?
- If the dominant problem is best addressed by a different specialty, if the disease is not yet medically optimized, if expectations are unrealistic, or if follow-up is geographically unworkable. Declining is a service to the patient, not a failure of one.
- What if I've been told I need wide excision?
- Many such patients still have a CO₂ tunnel-closure path. The consult exists to determine that — not the second opinion of another surgical team's plan.
- Do you see out-of-state patients?
- Yes. A structured virtual review with photographs and records is usually the first step; in-person evaluation is required before any procedure.
- Is this page a substitute for seeing a dermatologist?
- No. HS is co-managed. Our program assumes ongoing dermatologic care and coordinates with it.
Where to go next
If you're still reading
Two reasonable next steps. If you already know which procedure your case points toward, go deeper on the procedure page. If you're still triaging, the treatment overview is the right place.
CO₂ tunnel closure →Follicle-directed laser →The full treatment model →