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Managing Hidradenitis Suppurativa
Hidradenitis Suppurativa: Improving Outcomes With Early Screening and Novel Treatments

Released: April 22, 2025

Expiration: April 21, 2026

Amit Garg
Amit Garg, MD
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Key Takeaways
  • Patients’ symptoms on average start 10 years before they receive an HS diagnosis, leaving plenty of time for the disease to progress.  
  • Effective HS treatment requires an early diagnosis, as well as appropriate optimization of medical treatment with adalimumab, secukinumab, or bimekizumab. 
  • HS is associated with a myriad of comorbidities that require screening, diagnosis, and aggressive management following a multidisciplinary model of care. 

Hidradenitis suppurativa (HS) is an inflammatory disease that is thought to be rooted in the follicular unit and affects intertriginous areas of the body, including the axillae, under the breasts, in the groin, as well as the genitalia and buttocks. The disease presents with many types of lesions, and the ones that appear to have a significant impact on patients are inflammatory nodules, abscesses, and tunnels that drain and eventuate in rope-like scars.

It is a disease with an incredibly high symptom burden. Patients experience pain and fatigue, as well as unpredictable disease flares that can result in more lesions and greater symptom burden. In addition to the integumentary disease burden, HS is also known to be associated with several comorbid conditions that involve almost every organ system and contributes to patients experiencing significant psychosocial and physical burden.    

Early HS Diagnosis Is Critical 
Given its high symptom burden and progressive nature, HS warrants early recognition and aggressive management. HS recognition in ambulatory and acute-care settings has been problematic since the disease can mimic other common conditions such as abscess or cellulitis. Studies estimate that patients in the United States endure 10 years’ time between the onset of symptoms and HS diagnosis. During that time, patients often experience fragmented care, suboptimal treatments geared toward infections, and disease progression.   

With an awareness of how HS presents, diagnosis can be distinguished from common mimic conditions. Typical HS lesions include nodules, abscesses, and tunnels that may drain, along with the formation of rope-like scars. These lesions are most commonly present under the arms or breasts, in the groin, and around the genitalia or buttocks. The third feature is the recurring nature of these lesions in those same affected areas. In HS, abscess typically recurs in the same anatomic area for each patient. In contrast, other abscess conditions are not typically recurrent in the same anatomic area. Tunnels that may drain and rope-like scars are unique to HS.   

Current HS Treatment Landscape 
The goal of treating patients with HS is to adequately control symptoms and ideally modify the course of disease progression. Colleagues in other specialties should also screen patients with HS for age-appropriate and comorbid conditions, as well as conditions for which patients with HS are at disproportionate risk.   

There are now 3 FDA-approved treatments available for moderate to severe HS. These are biologic cytokine inhibitors including adalimumab (tumor necrosis factor inhibitor), secukinumab (IL-17A inhibitor), and bimekizumab (IL-17A and IL-17F inhibitor). All 3 agents have shown good efficacy and safety in pivotal clinical trials.   

I generally tell my patients who are considering one of these agents that approximately one half of users experience a 50% improvement in disease activity. We also know that the medications are more effective the longer a patient stays on them. This is a significant improvement in terms of addressing overall symptom efficacy compared with what can be achieved with traditional treatments that demonstrate limited evidence to support their use. Furthermore, the FDA-approved agents reduce pain and flare frequency and improve quality of life. For example, bimekizumab has shown durable response up to 2 years. In addition, a meaningful proportion of patients achieved a greater depth of response than the initial 50% response. The safety profiles of the 3 approved agents are excellent, and the benefit of using these medications for a condition like HS far outweighs the risks, which are generally very few.  

Common Comorbidities and Role of Multidisciplinary Care 
HS is known to have strong and independent associations with a number of comorbidities. Among the most common are psychological ones, including depression, anxiety, and suicidality. In addition, up to 25% of patients with HS also have diabetes mellitus, and almost 10% of women with HS have polycystic ovarian syndrome. A smaller but significant percentage of patients have inflammatory bowel disease, inflammatory arthritis, and uveitis. There are also rare but important associations with major adverse cardiac events like myocardial infarction and stroke. Women with HS are also known to have adverse pregnancy-related outcomes. There is also a very strong association between HS and Down syndrome. I now screen all patients with Down syndrome for HS, regardless of their reason for presentation.    

HS is also associated with obesity and tobacco smoking. Based on epidemiologic data, it seems likely that both comorbidities influence disease development. However, they are not sole factors in the disease development, as there are many other known and unknown contributions. Therefore, it is important that we as treating healthcare professionals do not assign blame to patients for having HS. Before engaging in a discussion around weight management and smoking cessation, it is important to first develop a strong therapeutic relationship with patients. There should be trust between healthcare professionals and patients when addressing these sensitive topics.     

Future Directions in HS Management 
There is a flurry of HS pipeline activity, and I am optimistic that in approximately the next 2 years we will have FDA approval for additional agents representing new mechanisms of action for treating moderate to severe HS. I believe that Janus kinase inhibitors will be the next class of medications likely to achieve regulatory approval.  

Since we have very good treatment options, it is important that we identify HS early and manage it as aggressively as possible. The FDA-approved agents are indicated for patients with moderate to severe disease. In clinical trials, this has included patients who present with 3-5 abscesses or inflammatory nodules, or at least one tunnel or rope-like scar (ie, Hurley stage II or III) affecting 2 or more areas.    

 Your Thoughts
How often are you prescribing secukinumab or bimekizumab in your practice for patients with HS? To learn more about HS, join us for our upcoming webinar on April 26, 2025. Use this link to register for the program: practicingclinicians.com/DermInt2025

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How often are you prescribing secukinumab or bimekizumab in your practice for patients with HS?

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