The full picture
Where we fit in the HS treatment ladder
HS care is not a single specialty's responsibility. The full ladder runs from lifestyle to reconstructive surgery, and most patients will sit on several rungs over the course of their disease. We are rungs 3 and 4 — the procedural laser tier between systemic medical therapy and excisional reconstruction.
Lifestyle & topical care
Patient + primary careSmoking cessation, weight management where relevant, gentle antiseptic washes, friction reduction. Foundation, not treatment in isolation.
Systemic medical therapy
Dermatology / rheumatologyOral antibiotics for anti-inflammatory effect, hormonal modulation, and biologic agents (adalimumab, secukinumab). The medical arm of HS control.
Follicle-directed laser therapy
UsLong-pulsed laser sessions that reduce the follicular population driving inflammation. The procedural answer to active disease.
1470 nm intralesional tunnel closure
UsA thin radial laser fiber is introduced through an existing tract opening and slowly withdrawn while coagulating the lining. No skin incision, no excision, no open wound — substantially less tissue impact than wide excision.
Wide excision & flap reconstruction
Plastic / general surgeryFor diffuse Hurley III or cases beyond what laser closure can address. We refer when this is the right answer.
Principles
Three principles that govern every plan
01
Match the tool to the tissue.
Inflammatory tissue and an organized sinus tract are different problems. Medicine quiets inflammation. Procedures remove structures. Confusing the two leads to under-treatment in one direction and over-treatment in the other.
02
Use the smallest intervention that does the job.
Tissue preservation is a clinical priority. In the perianal, perineal, and gluteal regions especially, conservative technique is what protects function — continence, mobility, sensation. This is not a marketing line; it is the reason we built the practice around laser closure.
03
Stay coordinated with the medical team.
HS is chronic. Patients who undergo a procedure but stop their biologic, or who never had a dermatologist in the first place, do worse. We expect — and prefer — that your medical team continues their work in parallel.
Laser 1
Follicle-directed laser therapy
A long-pulsed laser delivered to the affected regions reduces the population of hair follicles whose occlusion and rupture drive HS inflammation. With fewer functional follicles, there are fewer events that can flare.
What it does
Reduces flare frequency, quiets active inflammation, and in many patients slows progression toward tunnel formation. Most useful when disease is still primarily inflammatory.
Best for
Hurley stage I and selected Hurley stage II patients. Also used alongside intralesional tunnel closure to quiet the surrounding field.
What it does not do
Does not close established sinus tracts. Does not replace systemic medical therapy. Does not cure HS.
Treatment course
Typically 4–6 office-based sessions spaced 4–6 weeks apart. No general anesthesia. Most patients return to ordinary activity the same day.
Laser 2
1470 nm intralesional laser tunnel closure
Once HS has organized into sinus tracts, no medical therapy can close them. A thin 1470 nm diode laser radial fiber is introduced through an existing surface opening, advanced through the tract, and slowly withdrawn while coagulating the tract lining from within. The tract collapses and closes. No skin incision, no excision, no open wound — the same in-office closed-wound approach Dr. Kamrava uses in his pilonidal SiLaC program, applied to HS tunnel anatomy.
What it does
Acts on each established sinus tract from within, coagulating the lining circumferentially. Surrounding tissue is preserved entirely.
Best for
Hurley II and selected Hurley III patients with accessible tracts. Particularly suited to perianal, perineal, gluteal, and inguinal disease.
What it does not do
Does not treat active inflammation. Does not prevent new tracts from forming if the underlying inflammation is not controlled medically and with 1064 nm follicle therapy. Diffuse Hurley III may still require staged plans or referral.
Procedure setting
In-office procedure suite. Local infiltration anesthesia; NitroNox available for anxiolysis. No IV sedation, no general anesthesia, no hospital admission. Walk in, walk out.
Sequencing
How the two are sequenced
Most plans use one laser, some use both, and some use neither. The decision is made case by case, not by stage alone.
When we use both
Active inflammation plus established tracts. Follicle therapy quiets the field; intralesional closure removes the tracts. Order depends on which dimension is dominant.
When we use one
Early disease without tracts → follicle therapy alone. Established tracts in a relatively quiet field → intralesional closure alone, with medical co-management.
When we use neither
Medical regimen not yet optimized — we ask dermatology to lead first. Disease extent beyond our model — we refer to a reconstructive team.
Exclusions
What we do not do
A focused practice is defined as much by what it declines as by what it offers. The list below is honest, not exhaustive.
- We do not prescribe biologics or manage your long-term medical regimen — your dermatologist or rheumatologist remains the medical lead.
- We do not perform wide excision with flap reconstruction in our outpatient setting; when that is the right answer, we refer.
- We do not focus on isolated axillary HS — it is well served by dermatologic surgery programs closer to most patients.
- We do not promise cure. HS is chronic; our protocol is for durable control.
- We do not accept cases where we believe another team would produce a better outcome. Saying no is part of the practice.
Co-management
Working with your medical team
We work alongside dermatologists and rheumatologists, not around them. Before treatment we ask for your current regimen and any imaging or biopsy reports. After treatment we send operative notes, photographs, and a written summary of what we did and what we recommend next.
Most patients continue biologic therapy through the procedural course. We coordinate timing with your prescribing physician when a brief hold is warranted; in most cases it is not.
If you do not currently have a dermatologist managing your HS, we will help you find one. Long-term medical control is what protects the result of any procedure we perform.
Cost & insurance
An honest framing
HS procedural care is variably covered. We are out-of-network for most commercial plans and provide superbills for reimbursement. Financing options are available for patients who need them. We discuss specific costs after a consultation, once the plan is defined — quoting a number before we know what the procedure entails would not be honest.
Recovery
What recovery looks like
Follicle therapy sessions are office-based and most patients resume ordinary activity the same day. 1470 nm intralesional tunnel closure is closed-wound — most patients walk out the same day and return to desk work the next day, with no daily dressing changes and no extended restrictions.