Hidradenitis Suppurativa Hurley Stage III

A 34-year-old man with a 9-year history of recurrent painful boils in the axillae and groins presents with constant drainage and significant functional impairment. Examination of the left axilla reveals extensive, deeply violaceous, indurated skin with multiple actively draining abscesses, double-ended comedones, and rope-like scarring. The structure marked **A** in the diagram—interconnected sinus tracts with bridging scars—is the pathognomonic finding that distinguishes this presentation from earlier Hurley stages. Which of the following best describes the clinical significance of this finding in determining disease severity and guiding management?

A 32-year-old woman with obesity and a 15 pack-year smoking history presents with a 9-year history of painful, malodorous abscesses in the axillae and inframammary folds. Examination reveals confluent, interconnected sinus tracts, double-ended comedones, thick hypertrophic scarring, and multiple draining abscesses across the entire axillary and inframammary regions, as shown in the diagram marked **A**. She has failed multiple courses of antibiotics and incision-and-drainage procedures. Her DLQI is 27, indicating severe quality-of-life impairment. Which of the following is the most appropriate next step in management for this stage of hidradenitis suppurativa?