Hidradenitis suppurativa (HS) remains one of the most challenging chronic inflammatory diseases seen in dermatology. At the 2025 Skin Of Color Update conference in New York City, Dr. Tiffany Mayo led a case-based discussion on emerging therapies and management strategies for HS, with an emphasis on patients with skin of color.
HS affects between 0.1-4% of the population and is more common in women and African Americans. Given the average time to diagnosis is 7–10 years, it is likely the true incidence of HS is on the higher side of this estimate. Dr. Mayo highlighted a simple screening question, “Have you had at least two boils in the past 6 months?” which has been shown to be 90% sensitive and 97% specific for diagnosing HS. Earlier recognition and proactive management can help mitigate the significant physical and psychosocial burden of this disease.
Understanding HS Beyond the Skin
HS pathogenesis is complex, involving both the innate and adaptive immune systems. Although obesity and smoking are associated risk factors, they are not causative and overemphasizing them places unnecessary blame on patients. Other common comorbidities include metabolic syndrome, non-alcoholic fatty liver disease, type 2 diabetes, depression and sexual dysfunction, and other psychosocial issues. Dermatologists may not directly manage all of these conditions, but collaboration with primary care, endocrinology, and mental health providers is essential.
Addressing HS Chronicity and Management Expectations
Dr. Mayo highlighted some key phrases to help build rapport with patients who present with HS:
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- HS is not an infection
- HS is not due to poor hygiene
- Obesity is not the cause
- HS is not just a skin disease
- Most importantly: HS is not your fault
It is important to set the expectation for patients that HS is a chronic condition, and the treatment goal is to control inflammation and flares rather than achieve a cure. Recent guidelines from the United States and from Europe now provide algorithms for holistic care of HS patients, tailoring management to mild, moderate, or severe disease, and distinguishing between active flares and maintenance therapy.
Dr. Mayo provided a case-based overview of the therapeutic ladder for HS, as well as some challenges in diagnosis and management of HS patients with skin of color.
Case 1: “Bumps keep appearing” – Managing recurrent flares
A 26-year-old woman with recurrent boils flaring every few months highlights the importance of combining flare control and long-term prevention. Some first-line HS treatments are listed below.
Antibiotics:
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- Doxycycline is a common first-line therapy
- Clindamycin + rifampin (8 to 12-week treatment time; there is some evidence clindamycin monotherapy may be equally effective)
- Dapsone 50–200 mg
- Combinations of moxifloxacin + rifampin + metronidazole
- Intravenous ertapenem is highly effective, but restricted to severe refractory disease
Hormonal therapies:
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- Oral contraceptives can be effective for inflammatory nodules
- Spironolactone 75–125 mg daily generally does not cause side effects (headaches, breast tenderness, etc.)
- Metformin reduces inflammatory nodules and is safe for adults and pediatrics
- Finasteride 1–5 mg daily can also be used but should be avoided in adolescent girls and women of child-bearing potential
Other systemic options:
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- Retinoids (isotretinoin, acitretin) are effective, but must be avoided in women of childbearing potential
- PDE4 inhibitors (apremilast, roflumilast) can be used off-label
In this case, the patient continued OCPs but had to discontinue doxycycline due to vaginal candidiasis, demonstrating the challenge of balancing tolerability and efficacy in oral-based regimens.
Case 2: “Afraid to go anywhere because of flares” – The need for long-term control
The second patient had tried oral antibiotics, had multiple incision and drainage procedures, and continued to flare monthly with severe pain and mobility limitations. She was afraid to travel due to flares. Anxiety due to HS is affecting her lifestyle, almost leading to social withdrawal.
Patients with frequent flares often progress to systemic immunomodulators. Some of these are listed below.
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- Adalimumab: First FDA-approved biologic (based on the pivotal PIONEER I/II trials), effective for long-term maintenance
- Infliximab: Off-label, weight-based dosing up to 10 mg/kg every 4 weeks for high inflammatory burden
- Secukinumab (IL-17A inhibitor): Long-term HiSCR improvements over 2 years
- Bimekizumab (IL-17A/F inhibitor): HiSCR rates up to 80–100% with durable response through 96 weeks
- Povorcitinib (JAK1 inhibitor): Phase 2 trial showed ~50% achieving HiSCR50
A robust pipeline is emerging, including additional IL-17, IL-1, and JAK/STAT inhibitors, offering hope for patients with refractory HS.
Case 3: “I’m pregnant” – Navigating safe options
While patients may believe HS improves in pregnancy, data show that most (72%) experience no change, 20% improve, and 8% might worsen. Treatments that are safe in pregnancy include:
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- Topicals: clindamycin, benzoyl peroxide, chlorhexidine
- Oral antibiotics: clindamycin, cephalexin, amoxicillin-clavulanate, cefdinir
- Biologics: adalimumab and infliximab are category B; certolizumab is particularly useful as it lacks the Fc region, preventing placental transfer
Medications to avoid include tetracyclines, oral retinoids, spironolactone, and methotrexate.
Case 4: “My regimen is good except for one spot” – Role of procedures
For patients well-controlled systemically but experiencing localized breakthrough lesions:
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- Intralesional corticosteroids are a mainstay treatment for acute nodules
- Deroofing procedures, which remove the sinus roof and allow secondary intention healing within ~4 weeks, can provide durable relief
Case 5: “This is depressing, I’m the only one like this” – Addressing psychosocial burden
HS is deeply isolating. Patients benefit from psychosocial support and connection with others who understand their journey. Resources include:
Encouraging community and support groups can help reduce depression, anxiety, and social withdrawal.
References
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- Vinding GR, Miller IM, Zarchi K, Ibler KS, Ellervik C, Jemec GB. The prevalence of inverse recurrent suppuration: a population-based study of possible hidradenitis suppurativa. Br J Dermatol. 2014;170(4):884-889. doi:10.1111/bjd.12787
- Sabat R, Alavi A, Wolk K, et al. Hidradenitis suppurativa. Lancet. 2025;405(10476):420-438. doi:10.1016/S0140-6736(24)02475-9
- Zouboulis CC, Bechara FG, Benhadou F, et al. European S2k guidelines for hidradenitis suppurativa/acne inversa part 2: Treatment. J Eur Acad Dermatol Venereol. 2025;39(5):899-941. doi:10.1111/jdv.20472
This information was presented at the 2025 Skin of Color Update conference by Tiffany T. Mayo, MD, FAAD. The above highlights from her lecture were written and compiled by Riyad N.H. Seervai, MD, PhD.