The pathogenesis of acne inversa is follicular hyperkeratosis with occlusion and rupture. The subsequent acute inflammatory response leads to erythema, abscesses, fistulas, sinus tracts and scarring. Sites of predilection are the intertriginous regions. Many conservative therapies have only a supportive character. Therapy of choice is the early surgical intervention with complete excision of the involved areas, as conservative therapy is at best supportive. Although healing by second intention is preferred, all variations of flaps and grafts have been used. Usually the course of acne inversa lasts years until patients elect surgery after a physical and psychological odyssey.