Pediatric Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease that frequently begins during childhood or adolescence. Nearly one-third of individuals with HS report disease onset during the pediatric years, yet diagnostic delays of 2 to 3 years are common, allowing progression to scarring, chronic pain, and significant psychosocial burden.¹^,² For dermatologists, early recognition and timely escalation of therapy represent a critical opportunity to modify disease trajectory.

This article provides a practical, clinic-ready approach to pediatric HS, focusing on diagnostic recognition, comorbidity screening, severity-based management, and procedural and psychosocial considerations unique to children and adolescents.

RECOGNIZING PEDIATRIC HS

Pediatric HS most commonly presents in early adolescence, with a mean age of onset between 11 and 13 years and a strong female predominance (approximately 78% to 80%).² Anatomic distribution may vary by sex, with axillary involvement more common in males (93% vs 63%) and groin involvement more frequent in females (59% vs 29%).²

Diagnosis is clinical and requires all three of the following criteria:³^,⁴

• Typical lesions (painful nodules, abscesses, draining tunnels, or scarring)
• Involvement of intertriginous areas (though HS lesions may occur in any hair-bearing region)

Recurrence

Despite these straightforward criteria, pediatric HS is often misdiagnosed as recurrent infection or “boils.” In a large international cohort of 481 pediatric patients, nearly half (48%) already demonstrated scarring at their initial dermatology visit, highlighting the need for heightened clinical suspicion.²

DIFFERENTIAL DIAGNOSIS & SPECIAL POPULATIONS

Several conditions can mimic or overlap with HS in children and should be considered based on age of onset, distribution, and systemic features (Table 1).

Chronic granulomatous disease (CGD) is an important differential diagnosis in pediatric patients with recurrent skin abscesses. While most CGD patients are diagnosed before age 5 years (median 2.5 to 3 years), CGD should be considered in children presenting with HS-like lesions at any age when accompanied by recurrent severe infections, unusual pathogens (catalase-positive bacteria, Aspergillus), family history of immunodeficiency, or other systemic features such as pulmonary infections or lymphadenitis. Dihydrorhodamine (DHR) flow cytometry is the recommended screening test when CGD is suspected.¹^,⁵

Crohn's disease should be considered in patients with chronic gastrointestinal symptoms (abdominal pain ≥3 times weekly for ≥4 weeks, chronic diarrhea, or hematochezia) or extensive perianal disease. Fecal calprotectin is a useful initial screening test, with levels >250 μg/g warranting referral for endoscopic evaluation after exclusion of infectious causes.^6-8

Other mimickers include recurrent furunculosis, pilonidal disease, atypical mycobacterial infection, and actinomycosis.⁹

Special populations characterized by early HS onset include:

• Familial HS: Approximately 40% of pediatric cases report a positive family history, often associated with earlier onset and increased disease severity.²
• Patients with trisomy 21: This is a distinct population, as HS often presents at younger ages and may be more severe. The prevalence of HS among patients with Down syndrome is 2.1%, compared with 0.3% in the general population, with earlier onset (81.8% diagnosed by age 29 years vs 34.0% in those without Down syndrome).^10-12
• Precocious puberty: HS in prepubertal children (≤11 years) warrants endocrine evaluation, including Tanner staging, bone age assessment, and hormone levels (LH, FSH, estradiol/testosterone); 61% have a positive family history.⁹

COMORBIDITY SCREENING

Pediatric HS is strongly associated with systemic and psychiatric comorbidities, with 34% to 93% of patients having at least one comorbidity.^1,2 Routine screening is essential.

Metabolic comorbidities are frequently associated with pediatric HS and should be actively screened, as they can impact disease severity and long-term health outcomes. Key considerations include:

• Obesity affects approximately 37% of adolescents with HS, compared with 18.5% of the general pediatric population.¹²
• Type 2 diabetes occurs in approximately 4% of pediatric patients with HS; screen at-risk patients with fasting glucose or hemoglobin A1c.¹²
• Polycystic ovary syndrome (PCOS) affects 5%–7% of female patients and should be evaluated when menstrual irregularities or hyperandrogenism are present.⁹
• Psychosocial impact is significant in pediatric HS, with anxiety affecting 18% and depression 11.7% of patients—nearly three times higher than the general pediatric population. Suicidal ideation or attempts occur in 9% of cases. Mental health risk does not reliably correlate with disease severity, so all patients should undergo routine screening using validated tools such as the Patient Health Questionnaire-2 (PHQ-2) for depression and the Screen for Child Anxiety Related Emotional Disorders (SCARED) for anxiety, with prompt referral to mental health services as needed.^1,12

ASSESSING DISEASE SEVERITY

Severity assessment guides treatment escalation. The International Hidradenitis Suppurativa Severity Score System (IHS4) is preferred for clinical decision-making:

• IHS4 = (nodules ×1) + (abscesses ×2) + (draining tunnels ×4).³
• Scores classify disease as mild (≤3), moderate (4–10), or severe (≥11).

It is important to note that, for insurance purposes, Hurley staging and abscess/nodule counts should also be documented.

TREATMENT APPROACH

Foundational Interventions

All pediatric patients with HS benefit from baseline interventions, regardless of severity. These include daily antiseptic washes (chlorhexidine, benzoyl peroxide, or hypochlorous acid), age-appropriate pain control (acetaminophen, ibuprofen, topical lidocaine, and warm compresses), and lifestyle counseling focused on weight management, smoking avoidance (including vaping), and friction reduction.^13,14

Patient education is critical. Families should understand that HS is a chronic inflammatory disease—not an infection or the result of poor hygiene—and that meaningful improvement often requires at least 12 weeks of therapy. A practical approach to counseling pediatric patients can be found in Table 2.

Severity-Based Treatment

Mild Disease 

Topical clindamycin 1% applied twice daily as needed for flares remains first-line therapy.^3,13

Intralesional triamcinolone 10 mg/mL to 40 mg/mL (0.2 mL to 2.0 mL) provides rapid pain relief within 24 to 48 hours for isolated nodules or abscesses.^3,13 Ultrasound guidance improves outcomes (81% complete response for nodules at 12 weeks).³

For children unable to tolerate procedures during flares—such as those with developmental delay or needle phobia—topical clobetasol 0.05% ointment twice daily may be used, but only on active, painful lesions and never on the face.

Moderate Disease

Oral tetracyclines (doxycycline monohydrate) 100 mg twice daily for 12 weeks are first-line therapy in adolescents; they demonstrate similar efficacy to rifampicin/clindamycin with a better safety profile.^3,15 They are mostly used as a bridge before biologics. Importantly, tetracyclines are contraindicated in patients younger than 8 years because of the risk of dental staining.¹³

Rifampicin/clindamycin (rifampicin 300 mg plus clindamycin 300 mg twice daily for 12 weeks) is considered second-line; 48% achieve a 50% reduction, but 27% to 56% discontinue therapy because of adverse effects.^3,13,15

Early discussion of biologic therapy is recommended, as prolonged therapeutic delay is associated with poorer response.¹⁶

Moderate-to-Severe Disease

Adalimumab (tumor necrosis factor [TNF] α inhibitor) is currently the only US Food and Drug Administration (FDA)-approved biologic for HS in adolescents aged ≥12 years weighing ≥30 kg.¹⁷ Pediatric dosing includes:¹⁷

• 30–59 kg: 80 mg at week 0, 40 mg at week 2, and 40 mg every 2 weeks beginning at week 4
• ≥60 kg: 160 mg at week 0, 80 mg at week 2, and 40 mg weekly or 80 mg every 2 weeks beginning at week 4

The recommended adolescent dosage (40 mg every other week for 30- to 59-kg patients) was associated with the need for dose intensification; adult dosing regimens were more frequently used in practice.¹⁶

Early initiation is critical—therapeutic delay >10 years is associated with lack of response.¹³ Real-world pediatric data demonstrate high effectiveness, with 76.9% of adolescents achieving Hidradenitis Suppurativa Clinical Response (HiSCR) at 6 months—often exceeding adult trial response rates (42% to 59% at week 12).^16,18 Of note, a recent network meta-analysis ranked adalimumab weekly among the most effective regimens for moderate-to-severe HS.¹⁹

Off-label biologics, including ustekinumab and secukinumab (both approved for plaque psoriasis in patients aged ≥6 years), may be considered in refractory cases, contraindications to TNF α inhibitors, or if antidrug antibodies develop. Ustekinumab offers the unique advantage of dosing every 12 weeks; however, insurance approval can be difficult. Additional off-label treatment options include infliximab (with weight-based dosing, though infusion requirements may be challenging for some pediatric patients). Janus kinase inhibitors have shown promise in adult studies of moderate-to-severe HS, though these agents are not yet FDA approved for HS.²⁰

Managing expectations is crucial—the goal with biologic therapy is a 50% reduction in flares plus no progression to new anatomic areas .

HORMONAL THERAPY

For Patients Independent of Gender

Metformin (500 mg 2–3 times daily) is a useful adjunct in both male and female pediatric patients with insulin resistance or PCOS and HS. Metformin is FDA approved for type 2 diabetes in children aged ≥10 years and has been studied as adjunctive therapy in pediatric patients with HS with metabolic comorbidities, with 50% showing improvement in a retrospective series.^21,22 While metformin may be used off-label in younger children for metabolic conditions under endocrinology guidance, pediatric HS–specific data are limited to adolescents.

Glucagon-like peptide-1 (GLP-1) receptor agonists are FDA approved for obesity in adolescents aged ≥12 years (liraglutide was approved in 2020; semaglutide was approved in 2022).²³ Emerging adult data suggest potential benefit in HS through both weight reduction and anti-inflammatory effects, though no pediatric HS–specific studies have been published.^24,25 These agents may be considered in adolescents with HS and obesity in collaboration with pediatric endocrinology, recognizing that all current HS efficacy data are extrapolated from adult populations.

In Female Adolescents

Hormonal agents should be considered as monotherapy in adolescent females with mild-to-moderate HS or as adjunctive agents for more severe disease, particularly in patients reporting HS flares around menses or with features of PCOS, including hyperandrogenism (clinical or biochemical) with persistent oligomenorrhea.¹³

Spironolactone (50–200 mg daily) has demonstrated benefit in HS, with retrospective data showing improvement in 85% of patients (including adolescents and young adults) and complete remission in 55%, though severe disease was less responsive.¹³^,²⁶ Lower doses (approximately 75 mg daily) appear effective and well tolerated, with no significant difference in improvement between doses <75 mg and >100 mg daily.²⁶ A systematic review of hormonal treatments reported an overall response rate of 50.5% with spironolactone across all ages.²⁶ While pediatric-specific prospective data are limited, spironolactone is increasingly used in adolescent HS, particularly in those with features of hyperandrogenism or menstrual-related flares. There is no FDA minimum age cutoff.

Combined oral contraceptives have demonstrated benefit in HS. The only randomized clinical trial of hormonal therapy was a double-blind crossover study of 24 women comparing ethinyl estradiol/norgestrel with ethinyl estradiol/cyproterone acetate; both therapies resulted in similar improvement, with 50% of patients improving or clearing completely.¹³ While this study included young women, pediatric-specific data are limited. Estrogen-containing contraceptives are associated with better HS control compared with progesterone-only formulations. Most combined oral contraceptives are approved for patients aged ≥15 years.¹³

Finasteride (1–5 mg daily) has shown promising results in pediatric case series, with patients experiencing a decrease in the frequency and severity of disease flares. However, finasteride has high teratogenic potential, and pregnancy must be carefully avoided through effective contraception.²⁷^,²⁸ A practical summary of hormonal therapy for pediatric HS can be found in Table 3.

PROCEDURAL INTERVENTIONS

Incision and drainage: Reserved for acute abscesses requiring immediate pain relief; recurrence approaches 100%.^3,4

Deroofing: Tissue-saving technique with low recurrence (10% to 17%), high satisfaction (90%), and effectiveness for Hurley stages I–III.^3,4,14 It can be performed under local anesthesia.

Wide excision: For chronic, recurrent lesions with interconnected tunnels. Wide excision can range from removal of affected tissue with margins to complete regional excision (total exenteration of an anatomic area, such as all axillary tissue for Hurley stage III disease). Recurrence rates range from 20% to 27%, but complication rates are higher than with deroofing.^3,4,14 In experienced hands, complete regional excision can achieve very low recurrence rates, particularly in the axilla.⁴

Combining surgery with biologics: Adalimumab should not be interrupted during the perioperative period for dermatologic or plastic/reconstructive procedures.³

PAIN AND NEEDLE PHOBIA

Pain and needle anxiety are major barriers to care. A multimodal approach—including active distraction, vibration and cold devices (eg, Buzzy®), topical anesthetics, and Child Life specialist involvement—improves adherence and patient experience.²⁸

Practical tips to decrease pain and needle phobia for procedures or biologic injections can be found in Table 4.

CONCLUSION

HS frequently begins in adolescence, making pediatric dermatology a critical intervention point. Early diagnosis, systematic comorbidity screening, and timely escalation—particularly with biologic therapy—can prevent scarring and reduce lifelong morbidity. A practical, proactive approach is essential to improving outcomes in this vulnerable population. 

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2. Liy-Wong C, Kim M, Kirkorian AY, et al. Hidradenitis suppurativa in the pediatric population: an international, multicenter, retrospective, cross-sectional study of 481 pediatric patients. JAMA Dermatol. 2021;157(4):385-391. doi:10.1001/jamadermatol.2020.5435

3. Sabat R, Alavi A, Wolk K, et al. Hidradenitis suppurativa. Lancet. 2025;405(10476):420-438. doi:10.1016/S0140-6736(24)02475-9

4. Alikhan A, Sayed C, Alavi A, et al. North American clinical management guidelines for hidradenitis suppurativa: a publication from the United States and Canadian Hidradenitis Suppurativa Foundations: part I: diagnosis, evaluation, and the use of complementary and procedural management. J Am Acad Dermatol. 2019;81(1):76-90. doi:10.1016/j.jaad.2019.02.067

5. Choi E, Ooi XT, Chandran NS. Hidradenitis suppurativa in pediatric patients. J Am Acad Dermatol. 2022;86(1):140-147. doi:10.1016/j.jaad.2020.08.045

6. Ananthakrishnan AN, Adler J, Chachu KA, et al. AGA clinical practice guideline on the role of biomarkers for the management of Crohn’s disease. Gastroenterology. 2023;165(6):1367-1399. doi:10.1053/j.gastro.2023.09.029

7. Orfei M, Gasparetto M, Hensel KO, et al. Guidance on the interpretation of faecal calprotectin levels in children. PLoS One. 2021;16(2):e0246091. doi:10.1371/journal.pone.0246091

8. Walker GJ, Chanchlani N, Thomas A, et al. Primary care faecal calprotectin testing in children with suspected inflammatory bowel disease: a diagnostic accuracy study. Arch Dis Child. 2020;105(10):957-963. doi:10.1136/archdischild-2019-317823

9. Liy-Wong C, Pope E, Lara-Corrales I. Hidradenitis suppurativa in the pediatric population. J Am Acad Dermatol. 2015;73(5 Suppl 1):S36-41. doi:10.1016/j.jaad.2015.07.051

10. Garg A, Strunk A, Midura M, Papagermanos V, Pomerantz H. Prevalence of hidradenitis suppurativa among patients with Down syndrome: a population-based cross-sectional analysis. Br J Dermatol. 2018;178(3):697-703. doi:10.1111/bjd.15770

11. Lam M, Lai C, Almuhanna N, Alhusayen R. Hidradenitis suppurativa and Down syndrome: a systematic review and meta-analysis. Pediatr Dermatol. 2020;37(6):1044-1050. doi:10.1111/pde.14326

12. Mohsen ST, Price EL, Lara-Corrales I, Levy R, Sibbald C. Prevalence of comorbidities among pediatric patients with hidradenitis suppurativa: a meta-analysis. JAMA Dermatol. Published online 2025. doi:10.1001/jamadermatol.2025.1565

13. Alikhan A, Sayed C, Alavi A, et al. North American clinical management guidelines for hidradenitis suppurativa: a publication from the United States and Canadian Hidradenitis Suppurativa Foundations: part II: topical, intralesional, and systemic medical management. J Am Acad Dermatol. 2019;81(1):91-101. doi:10.1016/j.jaad.2019.02.068

14. Saunte DML, Jemec GBE. Hidradenitis suppurativa: advances in diagnosis and treatment. JAMA. 2017;318(20):2019-2032. doi:10.1001/jama.2017.16691

15. van Straalen KR, Tzellos T, Guillem P, et al. The efficacy and tolerability of tetracyclines and clindamycin plus rifampicin for the treatment of hidradenitis suppurativa: results of a prospective European cohort study. J Am Acad Dermatol. 2021;85(2):369-378. doi:10.1016/j.jaad.2020.12.089

16. Grau-Pérez M, Ciudad C, Molina-Leyva A, et al. ADOLESBIO-HS: a real-world multicenter case series on the effectiveness and safety of adalimumab in adolescents with moderate-to-severe hidradenitis suppurativa. Dermatology. Published online 2025:1-13. doi:10.1159/000546647

17. Adalimumab-adbm [package insert]. Silver Spring, MD: US Food and Drug Administration; updated November 12, 2024.

18. Kimball AB, Okun MM, Williams DA, et al. Two phase 3 trials of adalimumab for hidradenitis suppurativa. N Engl J Med. 2016;375(5):422-434. doi:10.1056/NEJMoa1504370

19. Garg A, Cohn E, Midgette B, Frasier K, Strunk A. Efficacy and safety of medical interventions for moderate to severe hidradenitis suppurativa: a living systematic review and network meta-analysis. JAMA Dermatol. 2025;161(9):931-940. doi:10.1001/jamadermatol.2025.1976

20. Kimball AB, Jemec GBE, Alavi A, et al. Secukinumab in moderate-to-severe hidradenitis suppurativa (SUNSHINE and SUNRISE): week 16 and week 52 results of two identical, multicentre, randomised, placebo-controlled, double-blind phase 3 trials. Lancet. 2023;401(10378):747-761. doi:10.1016/S0140-6736(23)00022-3

21. Moussa C, Wadowski L, Price H, Mirea L, O’Haver J. Metformin as adjunctive therapy for pediatric patients with hidradenitis suppurativa. J Drugs Dermatol. 2020;19(12):1231-1234. doi:10.36849/JDD.2020.5447

22. Masson R, Ma E, Parvathala N, et al. Efficacy of medical treatments for pediatric hidradenitis suppurativa: a systematic review. Pediatr Dermatol. 2023;40(5):775-788. doi:10.1111/pde.15404

23. Kelly AS, Armstrong SC, Michalsky MP, Fox CK. Obesity in adolescents: a review. JAMA. 2024;332(9):738-748. doi:10.1001/jama.2024.11809

24. Gouvrion L, Delage M, Villani AP, et al. Glucagon-like peptide-1 receptor agonists in hidradenitis suppurativa. JAMA Dermatol. Published online 2025. doi:10.1001/jamadermatol.2025.2723

25. Krajewski PK, Złotowska A, Szepietowski JC. The therapeutic potential of GLP-1 receptor agonists in the management of hidradenitis suppurativa: a systematic review of anti-inflammatory and metabolic effects. J Clin Med. 2024;13(21):6292. doi:10.3390/jcm13216292

26. Masson R, Shih T, Jeong C, Shi VY, Hsiao JL. Hormonal treatments in hidradenitis suppurativa: a systematic review. J Drugs Dermatol. 2023;22(8):785-794. doi:10.36849/jdd.7325

27. Randhawa HK, Hamilton J, Pope E. Finasteride for the treatment of hidradenitis suppurativa in children and adolescents. JAMA Dermatol. 2013 Jun;149(6):732-5. doi: 10.1001/jamadermatol.2013.2874. PMID: 23552442.

28. Mota F, Machado S, Selores M. Hidradenitis Suppurativa in Children Treated with Finasteride-A Case Series. Pediatr Dermatol. 2017 Sep;34(5):578-583. doi: 10.1111/pde.13216. Epub 2017 Jul 20. PMID: 28730603.

29. Birnie KA, Noel M, Chambers CT, Uman LS, Parker JA. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev. 2018;10:CD005179. doi:10.1002/14651858.CD005179.pub4