10 Tips for Managing Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a condition that demands a multifaceted approach to care. In an effort to assist the working dermatologist, we have provided the following HS management guide, which supplies actionable insights into optimizing HS management, emphasizing the importance of individualized care, timely interventions, and collaboration with multidisciplinary teams.

1. Wait to counsel on weight management and smoking cessation until after rapport has been established.

Hidradenitis suppurativa is a complex chronic condition that benefits from a longitudinal relationship with trust and open communication between dermatologists and patients. A survey study conducted in 2022 found that patients with HS prefer to prioritize topics such as symptoms, flare management, and personalized treatments plans during their first visit.¹ Although it is important to discuss weight management and smoking cessation strategies if applicable, a supportive and non-judgmental conversation should be conducted after strong patient-provider rapport has been established. 

2. Antibiotics should be utilized for HS flares or as a bridge to sustainable long-term therapy.

Systemic antibiotics may be used for shorter courses (2-3 weeks) for flares or for longer courses (2-3 months) as a bridge to appropriate long-term therapies such as hormonal/metabolic agents, biologics, and/or surgery. Commonly utilized antibiotics include doxycycline and clindamycin, which has often been combined with rifampin for added benefit. Monotherapy clindamycin has become more commonplace with recent literature suggesting that monotherapy clindamycin may have similar efficacy when compared to combination clindamycin/rifampin. Other monotherapy antibiotic agents to consider include cephalexin, cefdinir, amoxicillin-clavulanate, trimethroprim/sulfamethoxazole, and dapsone. For severe, recalcitrant HS, IV ertapenem for a duration of 6 to 12 weeks may be utilized as a rescue therapy.

3. Implement timely intervention with biologics.

There are currently three biologics approved by the US Food and Drug Administration (FDA) for moderate-to-severe HS: adalimumab, secukinumab, and most recently bimekizumab. Biologics are an appropriate long-term therapeutic option for HS and harness the potential to reduce overall systemic inflammation and improve disease outcomes. Just as we often consider isotretinoin for moderate inflammatory acne to prevent scarring, biologics may be considered for patients with moderate HS even if scarring or a tunnel is not present. 

4. Higher dosing and frequency of biologics typically needed for HS as compared to psoriasis.

Patients with HS typically require higher doses of biologics when compared to patients with psoriasis (see Table). This may be due to an overall higher inflammatory burden with HS. For example, adalimumab maintenance for moderate to severe plaque psoriasis is 40 mg every 2 weeks as opposed to maintenance dosing of 40 mg weekly or 80 mg every 2 weeks for HS. Infliximab is often used off-label for severe HS; studies evaluating optimal dosing suggest that higher dosing of 10 mg/kg every 4 weeks may be needed. If a patient has a partial response on a biologic, it can be helpful to trial either dose or frequency escalation of that biologic before switching to an alternative biologic. 

5. Utilize combination treatment strategies.

The pathogenesis of HS is complex with various factors playing a role including follicular occlusion, dysregulated inflammation, and hormonal and metabolic influences. Therefore, management often requires an individualized multi-modal approach with stacking of treatments from various therapeutic categories including topical agents, hormonal modulators, metabolic therapies, systemic antibiotics, immunomodulators, and procedures. As an example, a female patient with moderate-to-severe HS may be on a biologic (for long-term disease control) plus spironolactone (as a long-term treatment to help reduce hormonal HS flares) plus a systemic antibiotic (for a 3-month course as a bridge to help with more immediate symptom control). Once patients have been medically optimized, then surgical procedures such as deroofings and excisions should be considered for persistent areas as needed.

6. For patients with co-morbid obesity and/or diabetes or pre-diabetes, work with their primary care provider or endocrinologist to leverage a GLP-1 agonist.

There is a higher prevalence of comorbidities such as obesity and diabetes in patients with HS. Glucagon-like peptide (GLP)-1 agonists, such as semaglutide, are currently FDA-approved for diabetes. Preliminary data suggest that GLP-1 agonists may also be helpful in the management of HS. Although further studies are needed to better understand their efficacy in HS management, GLP-1 agonists may be considered in patients who have co-morbid obesity or diabetes. It can be helpful to communicate with your patient’s primary care provider or endocrinologist when considering the addition of a GLP-1 agonist.

7. Use in-office procedures to help alleviate HS flares.

Intralesional triamcinolone can be helpful for inflamed HS nodules or tunnels. Higher concentrations (40mg/cc) may be considered for larger lesions. Incision and drainage (I&D) can be offered for painful expanding abscesses. It is important to ensure that adequate local anesthesia has been achieved prior to incision. Injecting the anesthetic slowly can help optimize patient comfort during the procedure. We recommend incision using a punch tool (4-6 mm) as opposed to the traditional #11 blade, as the punch tool allows for continued drainage post-procedure. Avoid packing post I&D HS wounds, as packing is very painful for patients and there are no data suggesting additional benefit from doing so. 

8. Deroof or excise persistent lesions.

Surgical procedures, such as deroofings and excisions, play an important role in the management of HS and serve as adjuncts to medical management. Deroofings refer to the removal of the skin overlying HS tunnels or abscesses, whereas HS excisions remove the affected areas (overlying skin, debris, scar) down to the layer of the subcutaneous fat. These procedures should be implemented for fixed HS lesions such as tunnels or for areas that are recurrent despite medical optimization. HS deroofings and localized excisions can be completed with instruments available on a standard excision tray. A metal probe can be a helpful tool when deroofing tunnels, however if a probe is not readily available, then blunt scissors can be used to gently probe the involved areas to find the plane of the tunnel. Deroofings are generally well-tolerated, effective, and associated with high patient satisfaction. For larger excisions or for patients who require or prefer general anesthesia in an OR setting, we recommend referring to a trusted general or plastic surgeon. 

9. Ensure your patient has a primary care doctor.

Patients with HS have an increased risk of metabolic, cardiovascular, inflammatory and mental health comorbidities, so it is very helpful to partner with PCPs to ensure patients are having appropriate screening for: depression, generalized anxiety disorder, suicidality, smoking, substance use disorder, polycystic ovarian syndrome, obesity, hypertension, dyslipidemia, diabetes, metabolic syndrome, inflammatory bowel disease, and spondylarthritis. As dermatologists, we should screen HS patients for cutaneous comorbidities such as acne, dissecting cellulitis of the scalp, pilonidal disease, pyoderma gangrenosum. In addition, it is quick and easy to consider implementing depression screening for patients with HS in a dermatology clinic with the Patient Health Questionnaire (PHQ)-2 questionnaire (scored 0-6) and referring the patient to their PCP or to mental health professionals if the screen is positive (score of 3+).

10. Take advantage of helpful HS resources.

For clinicians, we recommend visiting the HS Foundation (HSF) website (hs-foundation.org) for prior authorization templates to help appeal for treatments that have been denied by insurance. There are helpful patient resources that you can also tell your patients about: The Papaya for HS app (hspapaya.com; available on iOS and Android) is a free platform that allows patients to track their disease and identify potential flare triggers, and provides up-to-date information on HS, access to an HS Patient Guide, and clinical trials opportunities. HS-specific support groups and resources are available in person and online through organizations such as Hope for HS (hopeforhs.org), HS Connect (HSconnect.org), and the International Association of HS Network (iahsn.org).

1. Shih T, De DR, Brooks B, Fixsen D, Shi VY, Hsiao JL. Optimizing hidradenitis suppurativa clinic visits: Patient perspectives. Int J

Womens Dermatol. 2022;8(3):e040. doi: 10.1097/JW9.0000000000000040.

Supplemental Reading

• Hengy M, Daveluy S. A simple video demonstrating the deroofing technique for hidradenitis suppurativa. JAAD. 2024;90(3):e89. doi:10.1016/j.jaad.2022.11.011
• JAAD CME Supplement. Hidradenitis Suppurativa: Embracing Progress. 2024;91(6S).
• Shi V, Hsaio J, Lowes M, Hamzavi I. A comprehensive guide to hidradenitis suppurativa: 1st edition. Elsevier, 2022.

Katrina H. Lee, MD

• Assistant Professor of Dermatology
• Keck School of Medicine, University of Southern California

Jennifer L. Hsiao, MD

• Associate Professor of Dermatology
• Keck School of Medicine, University of Southern California