Don’t Under-Treat Hidradenitis Suppurativa: A Roadmap from Hesitant to Confident

Hurley Stage III hidradenitis suppurative | Image credit: DermNet

When I first started working in dermatology almost 8 years ago, I’ll admit it—hidradenitis suppurativa (HS) felt overwhelming. It seemed too complex, too systemic, too unpredictable. I’d think, “This isn’t something I treat.” Sound familiar? I know I’m not alone in that hesitation. But here’s what I’ve learned: HS is far more common and impactful than we often realize, and it’s absolutely something we can—and should—treat. Patients with HS deserve better, and with the right tools, we can deliver.

As the distant co-chair for the Society of Dermatology Physician Assistants (SDPA), I had the fortunate ability to hear a comprehensive lecture on HS given by Dr. Tiffany Mayo, MD, FAAD, from the University of Alabama at Birmingham, and it was like hearing the talk I wish I’d heard 8 years ago. The full talk will be available to SDPA members, and here I review what was most impactful to me. The lecture provides practical clinical management that you will need, and I highly recommend viewing the full video. As I listened, it became clear that treating HS isn’t just possible—it’s necessary. With the right knowledge and strategies, we can move from hesitant to confident, and make a real difference in our patients’ lives.

Understanding Why HS Matters

First, let’s talk about what HS actually is. It’s not just painful bumps or abscesses. As Dr. Mayo explained, “HS is a systemic inflammatory condition… beyond just the skin.” Patients deal with painful, recurrent nodules and tunnels in sensitive areas like the underarms, groin, and buttocks. But it doesn’t stop there. HS is linked to metabolic issues, rheumatologic conditions, gastrointestinal disorders, psychological struggles, and even malignancies.

When we avoid addressing HS, we leave patients to navigate a condition that impacts their physical, emotional, and social well-being. Depression, anxiety, missed work, strained relationships—the toll of untreated HS is profound. But when we step up to treat it, we offer more than symptom relief. We offer patients their lives back.

Why We Hesitate—and How to Overcome It

I understand why providers hesitate. HS feels unpredictable—who will progress? Who will need systemic therapies? And then there are the “what ifs” of special populations: patients who are pregnant and pediatric cases. Dr. Mayo doesn’t sugarcoat it: “Man, that is the question to be answered, because then we would have it all figured out.” But here’s the thing: not knowing everything doesn’t mean we do nothing. Early intervention and adaptable treatment strategies are the way forward.

Consider patients who are pregnant, for example. It’s easy to hesitate out of safety concerns. But as Dr. Mayo emphasized, “They’re suffering, too, and so we need to be equipped.” With the right knowledge, we can offer solutions to almost any scenario. The goal isn’t perfection—it’s progress.

Starting Small: Laying the Foundation

So where do you start? With the basics. Dr. Mayo explained, “Every patient regardless of their stage… is going to get these topicals.” She’s talking about benzoyl peroxide washes, topical clindamycin, and other antiseptics. These simple steps create a foundation for care. They’re straightforward, effective, and easy to implement.

For mild disease, antibiotics can help. Doxycycline or clindamycin/rifampin combinations are short-term options for controlling flares. Hormonal therapies like oral contraceptives or spironolactone can stabilize lesion counts. Metformin can address both metabolic and inflammatory components. It’s about finding comfort with a range of options you can tailor to the individual.

When It’s Time for Systemic and Biologic Therapies

Patients with frequent flares or structural changes such as tunnels need more than topicals or antibiotics—they need systemic therapies, especially biologics. “For the patients who are constantly flaring, we need them on a biologic,” Dr. Mayo explained. Treatments such as adalimumab, secukinumab, and bimekizumab are FDA-approved for HS, and they’ve transformed the way we approach this disease.

Biologics used to feel like a last resort, but they’re now essential for long-term control. Nervous about special populations? TNF inhibitors such as adalimumab are pregnancy category B, making them safer than you might think. Metformin is also safe during pregnancy. Even pediatric patients can benefit from systemic therapies tailored to their needs. These insights were game-changing for me, and they’ve helped me approach even complex cases with more confidence.

Procedures and Beyond

Treating HS doesn’t stop at medications. Simple in-office procedures can make a huge difference. Intralesional Kenalog injections can reduce inflammation during flares. Deroofing minor tunnels can prevent the need for more invasive surgeries. Even laser hair removal has a role in reducing friction and inflammation. “We can do simple procedures in clinic,” Dr. Mayo reminded us. These aren’t complicated interventions—they’re practical steps we can incorporate into our practice.

Addressing Pain and Emotional Well-Being

Pain is a major issue for patients with HS, and validating that pain is important for building rapport. Dr. Mayo said it best: “If a patient says they’re flaring, they’re flaring.” Believe them. Treat their pain with anti-inflammatories, procedural interventions, or adjustments to systemic therapies. Don’t forget the emotional toll of HS, either. Depression and anxiety are common, and being ready to refer patients to mental health professionals can make a huge difference. A holistic approach strengthens trust and improves outcomes.

Building Your Confidence

If you’re feeling overwhelmed by all this information, I get it. After hearing Dr. Mayo’s lecture, my head was buzzing with ideas, too. But the key is to start small. Add a wash. Try a short-term antibiotic. Introduce a biologic for patients who need it most. Each step builds your confidence—and helps your patients.

Dr. Mayo left us with this takeaway: “Early diagnosis and appropriate treatment is the key.” Every patient you treat for HS is a patient who can regain control over their life. The journey from “I don’t treat HS” to “I’m ready to help” isn’t about knowing everything—it’s about being willing to learn, take action, and make a difference.

Michael Rubio, PA-C, is a primary care physician assistant specializing in dermatology based in Brooklyn, NY. He serves as the Distant Education Co-Chair for the Society of Dermatology Physician Assistants (SDPA) and contributes to the National Commission on Certification of Physician Assistants (NCCPA) in the development of the Certificate of Added Qualifications (CAQ) in Dermatology. Additionally, he is a co-founder of Well Revolution, a direct primary care company to increase care access through telemedicine across the United States.