Wound Healing After HS Surgery: What Happens in the First 90 Days

Written by Dr. rer. nat. Dennis Alexander Kwiatkowski

The published surgical literature on hidradenitis suppurativa (HS) reports outcomes in months and years. The patient experience of postoperative recovery is measured in days and weeks. The gap between these timeframes is where most of the confusion, anxiety, and avoidable complications happen. A patient who has not been told what an HS surgical wound looks like at day five, day twenty, or day sixty will read every variation as a sign that something is wrong.

This article walks through the first ninety days of wound healing after HS surgery — deroofing or excision, primarily — describing what actually happens, what is normal at each stage, what signals a problem, and what the practical wound care looks like. It complements the related articles on deroofing, wide excision, and the secondary intention versus flap closure decision.

Educational content only. Postoperative wound care should follow the specific instructions of your surgical team. The general patterns described below do not replace those instructions.

Key takeaways

• Most HS surgical wounds heal by secondary intention — the wound is left open and granulation tissue fills the defect from below while skin grows in from the edges.
• The biology proceeds in overlapping phases: inflammation (days 1–7), proliferation/granulation (week 1 to several weeks), and remodelling (months to over a year).
• Healing time depends mostly on wound size and site. A small deroofed lesion may close in two to three weeks. A large wide-excision wound healing by secondary intention may take three to six months.
• Negative pressure wound therapy (vacuum dressings, NPWT) is increasingly standard for larger wounds and meaningfully accelerates healing.
• A handful of clear warning signs — spreading redness, fever, foul-smelling discharge, abrupt pain increase, wound breakdown — warrant prompt clinical contact rather than waiting for the next routine visit.

How wound healing actually works

To know what to expect day by day, it helps to know what the underlying biology is doing.

After surgery, the wound goes through three overlapping phases:

Inflammation phase (roughly days 1 to 7). The body’s immediate response to tissue injury. The wound is red, often swollen, sometimes warm. White blood cells flood the area to clear debris and any bacterial contamination. There is typically serous drainage (clear-to-yellow fluid) and, in the first 24 to 48 hours, some bleeding. Pain peaks in the first 24 to 72 hours and then declines. The wound looks “angry” but this is not infection — it is the normal inflammatory response.

Proliferation phase (week 1 onwards, lasting weeks). Granulation tissue forms — the pink, slightly bumpy, vascular tissue that fills in the wound bed. Fibroblasts produce collagen, new blood vessels develop, and the wound progressively contracts as myofibroblasts pull the edges inward. Skin (epithelium) starts migrating from the wound edges, eventually meeting in the middle to close the defect. The wound looks pink and healthy-bumpy in this phase, with decreasing exudate over time.

Remodelling phase (months to over a year). Even after the wound is “closed,” the underlying scar tissue continues to remodel. Initial scar tissue is disorganized and weak; over months, collagen fibres are remodelled into stronger, more organized patterns. The scar gradually softens, flattens, and lightens, though it never regains the full strength of unwounded skin.

These phases overlap. A wound in week three is in the proliferation phase but may still have some inflammation at the edges and is just beginning early remodelling.

Week 0 to Week 1: the immediate postoperative period

Day 0 (day of surgery). You leave the operating theatre or clinic procedure room with a primary dressing in place. For a deroofing procedure under local anaesthesia, you go home the same day. For wider excisions under general anaesthesia, you may stay one to several days depending on the procedure and closure.

The dressing for the first 24 to 48 hours is usually left undisturbed unless it becomes saturated. Mild oozing through the dressing is normal; soaked dressings should be reinforced or changed earlier.

Days 1–3. Pain typically peaks in this window. Take prescribed or recommended analgesics on a regular schedule rather than waiting for pain to escalate. Mild to moderate pain is expected; severe pain warrants assessment.

The wound may produce more exudate than expected. This is normal — the inflammatory response is at its peak and dressings may need changing more frequently than the longer-term schedule. Some bleeding through the dressing in the first 24 hours is normal; bleeding that soaks through and continues warrants clinical contact.

You can usually shower from 24 to 48 hours after the procedure depending on dressing type and surgical instructions. Bathing in submerged water is generally avoided until later.

Days 4–7. Pain decreases substantially. Exudate volume usually plateaus or begins to decrease. The wound starts to look less raw and more healthy-pink as inflammation settles and early granulation begins. Around day 7, the first scheduled wound check often occurs, and dressing change frequency can sometimes be reduced.

For sutured wounds (primary closure or some flap closures), this is also typically when the surgical team assesses the closure integrity. Removable sutures may stay in for one to three weeks depending on site; absorbable sutures dissolve over weeks without removal.

Week 2 to Week 4: the granulation period

Week 2. The wound bed in a secondary-intention healing wound typically looks distinctly pink and bumpy — this is healthy granulation tissue and is exactly what should be happening. Drainage continues but is usually noticeably less than week one. Pain at this point is usually mild and intermittent.

For a small deroofing wound (a few centimetres), you may see visible reduction in the wound size at this point as epithelialization from the edges progresses. For larger wide-excision wounds, the wound size may still appear similar to baseline but the wound bed should be healthy and granulating.

Week 3. Continued granulation and progressive contraction. For small deroofed wounds, this is often when closure is essentially complete or nearly so. Healing time for the original van der Zee deroofing series averaged 14 days, with most wounds closed or near-closed by three weeks.

Week 4. For deroofed lesions in favourable sites (axillae, for example), the wound is often closed by this point. For larger wounds or wounds in less favourable sites (groin, perineum, gluteal cleft), the wound continues to granulate and shrink but is far from closed. Dressing changes can typically be every two to three days for moderately exudating wounds at this stage.

Week 5 to Week 8: the contracting wound

For small wounds that closed by week four, this is the early remodelling phase — the new scar is pink, soft, and gradually maturing.

For larger wounds still healing by secondary intention, this period is dominated by progressive wound contraction. The wound visibly shrinks week by week. Drainage decreases substantially. Pain is usually minimal.

The visible contraction is sometimes dramatic. A wound that was 8 cm across at week one may be 3 cm across by week six. This is mediated by myofibroblasts in the granulation tissue pulling the wound edges inward, combined with progressive epithelialization from the perimeter.

For wounds at this stage, dressing burden is usually substantially reduced from the early weeks. Many patients are doing dressing changes every two to three days with a foam dressing and continuing with normal activities outside the wound site.

For very large wide-excision wounds — particularly in the perineum, gluteal cleft, or extensive axillary disease — this period may still involve substantial wound size and ongoing wound care. The published mean healing time for wide excision with secondary intention is approximately 16 weeks, so a substantial proportion of patients are still in active wound care at week eight.

Week 9 to Week 12: late healing

For most uncomplicated wounds, by week 12 the wound is closed or very close to closed. The scar is pink, possibly slightly raised, soft to firm depending on site and individual variation.

For complicated or very large wounds, week 12 may still involve active wound management. Several patterns warrant honest acknowledgment:

• Slow-healing wounds in the perineum, gluteal cleft, or other moist friction-prone areas often take longer than the average. Mean healing times in published series of severe HS wide excision can extend to 4 to 6 months.
• Patients with diabetes, smoking, immunosuppression, or significant nutritional issues typically heal slower than average.
• Wounds that have had complications (infection, partial dehiscence, hypergranulation) take longer overall.

If you are at week 12 and the wound is still substantially open, this is not necessarily a failure. It is a reason to be in active follow-up with the surgical team to ensure the wound is progressing rather than stalled.

Months 4 to 12 and beyond: scar maturation

Once the wound is closed, scar maturation continues for many months.

Months 4 to 6. Scar tissue is typically pink, possibly slightly raised, sometimes itchy. It is at its weakest in terms of tensile strength compared to mature scar.

Months 6 to 12. Scar gradually softens, flattens, and lightens. Itchiness usually resolves. The scar progressively integrates visually with surrounding skin, though it remains visibly distinguishable.

Beyond 12 months. Continued slow remodelling. Final scar appearance is usually established by 12 to 18 months but can continue to refine for several years.

Hypertrophic scars (thick, raised, sometimes itchy or tender) can develop in some patients, particularly at sites of high tension or movement. Keloid scars (extending beyond the original wound boundary) are less common but possible, particularly in patients with darker skin types or a personal or family history of keloid formation. Both can be managed with intralesional steroid injections, silicone sheeting, or other scar therapies — discuss with the dermatologist or surgeon if scar appearance is problematic at six months.

Negative pressure wound therapy (NPWT / VAC)

For larger secondary-intention wounds, negative pressure wound therapy is increasingly standard and worth understanding.

The principle: a foam dressing is placed inside the wound, sealed with a transparent adhesive film, and connected to a vacuum pump that maintains constant negative pressure (typically -75 to -125 mmHg). This produces several effects: enhanced granulation tissue formation, reduced wound oedema, controlled exudate collection in a canister rather than into outer dressings, and progressive wound contraction.

Practical implications:

• The device is worn continuously, either as a portable pump on a belt or attached to a clinic-based unit.
• Dressing changes are typically every 48 to 72 hours, often performed by a wound care nurse or in the surgical clinic.
• Patient mobility is preserved with portable units.
• Exudate is contained in a canister rather than soaking through dressings — a substantial quality-of-life improvement for high-exudate wounds.
• Duration of use varies from one to six weeks depending on wound size and healing trajectory.

In Germany under GKV, negative pressure wound therapy is covered for appropriate indications. In other systems, coverage varies.

Wound care practicalities

Several practical points repeat for almost every postoperative HS wound:

Dressing choice. Most secondary-intention wounds use a foam dressing as the primary absorbent layer, sometimes with an alginate inside the wound for heavily exudating defects. Specific products are matched to wound state — see the companion article on HS dressings. Surgical teams typically prescribe specific dressing types for the first weeks.

Cleansing. Gentle showering is appropriate for most wounds from day one or two. Soap should not be scrubbed directly into the wound bed. Patting dry is preferred over rubbing. Saline rinsing during dressing changes is reasonable for cleansing accumulated debris.

What not to apply. Topical antibiotic ointments (Bacitracin, Neosporin) are not first-line for HS surgical wounds and frequent use can sensitize the skin. Hydrogen peroxide and undiluted alcohol damage granulating tissue and should not be applied to open wounds. Manuka honey dressings have a place in some chronic wound situations but should be used under surgical guidance, not freelance.

Mobility and positioning. Specific guidance depends on the site. Buttock and perineal wounds may require lying or specific positioning to reduce pressure. Axillary wounds need positioning that avoids direct pressure and reduces friction. Compression undergarments or specific support garments are sometimes prescribed.

Sleep. Wound location affects sleep position for the first weeks. A buttock or sacral wound may require side-sleeping. An axillary wound may make certain shoulder positions uncomfortable. Plan for this rather than being surprised by it.

Nutrition. Wound healing has substantial protein and micronutrient requirements. Adequate protein intake (often quoted as 1.2 to 1.5 g/kg/day for actively healing wounds, depending on patient size and metabolic status), adequate caloric intake, and adequate vitamin and mineral status all support healing. Patients with significant pre-operative nutritional deficits may benefit from formal nutritional assessment.

What is normal versus what is a warning sign

A reliable list of distinctions:

Normal:

• Pink granulation tissue at the wound base
• Mild redness at the immediate wound edges
• Yellow-tinged fibrinous slough on the wound surface (this is part of normal healing)
• Mild serous exudate
• Mild ache or discomfort at the wound site
• Gradual size reduction over weeks
• Some itching, particularly as the wound is closing
• Tenderness around the wound edges
• Mild bleeding during dressing change

Warning signs warranting prompt clinical contact:

• Spreading redness beyond the wound edges, especially if it expands more than a centimetre or two per day
• Fever (38°C / 100.4°F or higher) without other clear explanation
• Sudden severe pain increase out of proportion to the wound stage
• Foul-smelling discharge or discharge that has changed character abruptly
• Wound dehiscence (wound coming apart) for sutured wounds
• Increased depth or new tunneling in a wound that was previously progressing
• Bleeding that does not stop with light pressure for 10 to 15 minutes
• Black or grey tissue appearing in the wound bed (possible necrosis)
• Signs of systemic illness — nausea, malaise, chills

If in doubt, contact the surgical team. Most concerns turn out to be normal variations on expected healing; the cost of unnecessary contact is low and the cost of missing real complications is high.

In Germany specifically

Practical points for the German context:

Wound nursing care. Häusliche Krankenpflege (home nursing care) is covered under GKV for postoperative wound care when prescribed appropriately. A wound nurse can visit at home for dressing changes during the active healing period, which is particularly valuable for patients with limited mobility or wounds in hard-to-reach sites.

Wound dressings. Modern wound dressings prescribed (verordnet) for ongoing postoperative wound care are reimbursable under GKV — discuss prescription with your surgical team rather than buying everything yourself.

Specialized wound clinics. Several German regions have specialized wound care centres (Wundzentren) that can provide expertise for complex or slow-healing wounds. Referral typically comes from the surgical team or general practitioner.

Anschlussheilbehandlung (AHB). For patients undergoing extensive surgery with substantial recovery requirements, post-acute rehabilitation may be available and worth asking about.

Krankengeld. For prolonged work absence beyond the initial six weeks of employer salary continuation, sick pay through statutory health insurance applies.

Frequently asked questions

Why does my wound look worse before it looks better?

In the first week to ten days, the wound goes through peak inflammation and is at its most red, swollen, and angry-looking. This is normal and not a sign of infection. The transition from “wound” to “healing wound” happens around days 7 to 14 as inflammation settles and granulation tissue establishes.

Can I exercise during the healing period?

Light walking is usually appropriate from early in recovery. Significant exercise that produces sweating, friction, or pressure on the wound is generally avoided until the wound is well into the proliferation phase and ideally closed. Specific guidance depends on site and surgery type — ask your surgical team.

Is yellow stuff in the wound infection?

Not necessarily. Fibrinous yellow slough on the wound surface is a normal part of healing and looks superficially similar to pus. Frank pus tends to be thicker, foul-smelling, and accompanied by other signs of infection (increasing pain, expanding redness, fever). When in doubt, photograph and ask.

How can I make the wound heal faster?

The honest answer: not by much. The main controllable factors are adequate nutrition, stopping smoking, avoiding mechanical disruption of the wound, following dressing protocols, and managing comorbidities like diabetes well. None of these dramatically accelerate healing; collectively they prevent slow healing.

What if my wound stalls and stops getting smaller?

A wound that has stopped reducing in size for more than two to three weeks warrants reassessment. Possible causes include indolent infection, hypergranulation (overgrowth of granulation tissue), retained foreign material, recurrent disease in the wound bed, or systemic factors affecting healing. The surgical team should evaluate.

How long until I can wear normal clothes / shave / use deodorant again?

These depend entirely on wound site and healing status. As a rough guide, normal clothes over the area are usually possible once the wound is closed and the scar is intact, typically several weeks post-deroofing or several months post-large excision. Shaving and depilation over scar tissue should generally wait until the scar is fully mature, often 6+ months. Deodorant use over a healed axillary scar can typically resume cautiously after wound closure but should be discussed with the surgical team.

Will I have follow-up after the wound is healed?

Yes, ideally indefinitely for HS surgery. Long-term dermatology follow-up matters for surveillance of new disease and management of the underlying condition. Surgical follow-up may extend to one or two visits after wound closure for scar assessment.

Disclaimer. This article is for general education and does not constitute personal medical advice. Postoperative wound care should follow the specific instructions of your surgical team, who know your individual situation.