As Director of the Hidradenitis Suppurativa (HS) Clinic at the University of Southern California in Los Angeles, CA, Jennifer L. Hsiao, MD, has developed strategies to help make the most of first-time patient referrals, including taking her time.
“You don’t have to do everything on that first visit,” Hsiao says at a joint meeting of the California Society of Dermatology and Dermatologic Surgery (CalDerm) and the Pacific Dermatologic Association (PDA) in San Diego, CA. “Focus on establishing rapport and dispelling myths about HS. For example, reassure them that it’s not an infection, it’s not contagious, they’re not going to spread it to anyone, and that it’s not their fault. It’s important to emphasize that this is a chronic inflammatory skin disease.”
Her second tip is to seek guidance from updated resources to optimize care of HS patients. The 2019 North American clinical management guidelines for HS “are really outdated. Two of our three U.S. Food and Drug Administration (FDA)-approved therapies right now are interleukin (IL)-17 inhibitors—secukinumab (Cosentyx, Novartis) and bimekizumab (Bimzelx, UCB)—but they’re not even in the algorithm. There are efforts underway to put out new guidelines, and they can’t come quickly enough because a lot of times insurance will push back when we try to get meds for our patients.”
For now, she refers clinicians to an expert HS algorithm that she and other experts published in 20251. In addition to conventional approaches, the document outlines potential metabolic therapies, off-label biologic treatments, small molecule inhibitors, and other options.
Her third tip is to adopt a multimodal approach to treating HS. Topicals to consider include Hibiclens wash, benzoyl peroxide wash, CLn body wash, clindamycin 1%, and resorcinol 15%.
Other topicals that hold promise, she said, include AbbVie’s ruxolitinib (which is currently in Phase 3 trials for HS), roflumilast (Zoryve, Arcutis), tapinarof (Vtama, Organon), and clascoterone (Winlevi, Sun Pharma).
Options in the realm of systemic antibiotics include doxycycline, clindamycin, Augmentin, Bactrim, Keflex, cefdinir, and dapsone. Combinations that have shown efficacy include Bactrim DS plus Keflex; ciprofloxacin plus Flagyl; and rifampin plus Flagyl and moxifloxacin. “Remember: our goal with antibiotics is not long-term therapeutic management,” Hsiao says. “I use them in two ways. One is basically for one to two weeks as flare management. Or, I use it as a bridge therapy for about three months. For example, I might add an antibiotic concomitantly with a biologic or metabolic/hormonal therapy to try to cool things down faster while waiting for their long-term therapies to kick in.”
Hormonal therapies to consider include spironolactone, oral contraceptives, and finasteride. There is also a growing interest in the use of glucagon-like peptide-1 (GLP-1) receptor agonists. “Given the metabolic dysfunction and cardiovascular risk factors we often see in our patients, it’s easy to see why this class of medication might be helpful,” she says. Robust data supporting their use in HS are lacking, but in a retrospective study of 66 adults with HS and obesity who used GLP-1 agonists, French researchers found that at six months, 54% of patients achieved at least a one-point reduction in HS-Physician Global Assessment, and 60% experienced a reduction in flares2.
Hsiao’s fourth tip is to start biologics in a timely manner in patients with moderate-to-severe HS. To date, the strongest evidence exists for adalimumab, secukinumab, and bimekizumab. “A patient does not need a tunnel to be a biologic candidate,” she emphasizes. “I’m glad about that because our goal should be to try to prevent tissue destruction, prevent tunnels, and prevent scarring. Starting patients earlier on medications will result in a better chance of higher efficacy.”
The Role of Surgical Procedures in HS Treatment
Surgical procedures have an important place in HS care, too. In a separate presentation, Akhil Wadhera, MD, Regional Director of Laser Services and lead for cosmetic dermatology at Kaiser Permanente in Northern California, adds that office-based procedures such as laser hair removal and deroofing may lead to permanent remission in some patients. In a laser hair removal trial that he and colleagues performed in 82 patients—81% of whom had moderate to severe disease—74% of subjects with Hurley Stage I and II disease achieved a Hidradenitis Suppurativa Clinical Response (HiSCR), compared with 44% of subjects with Hurley Stage III disease. Results from a published systematic review and meta-analysis support the approach3.
“I hope the evidence will encourage other providers to start using laser hair removal for the treatment of HS, thus potentially avoiding the morbidity and cost burden of biologic medications,” Wadhera says. His hope is that insurance providers will follow the example of Kaiser Permanente, Northern California, and consider laser hair removal as medically indicated for many HS patients.
He adds that he and his colleagues have had success with the surgical treatment known as deroofing, in which the “roof” of an abscess, cyst, or sinus tract is removed, with or without the use of CO₂ lasers. This can be done in an outpatient setting with no general anesthesia. In his experience, deroofing results in lower rates of recurrence and complications compared to techniques involving primary closure or with grafts or flaps. “You’ll be so amazed at how grateful these patients are with the results,” Wadhera says.
–Doug Brunk
REFERENCES:
- Dagenet CB, Lee KH, Sayed C, et al. Comprehensive and Updated Algorithm of Hidradenitis Suppurativa Management from the Experts. Am J Clin Dermatol. 2025;26(4):487-497. https://pubmed.ncbi.nlm.nih.gov/40180764/
- J Gouvrion L, Delage M, Villani AP, et al. Glucagon-Like Peptide-1 Receptor Agonists in Hidradenitis Suppurativa. JAMA Dermatol. 2025:e252723. https://pubmed.ncbi.nlm.nih.gov/40802272/
- Shipman WD 3rd, Williams MN, Suozzi KC, et al. Efficacy of laser hair removal in hidradenitis suppurativa: A systematic review and meta-analysis. Lasers Surg Med. 2024;56(5):425-436. https://pubmed.ncbi.nlm.nih.gov/38769894/
PHOTO CREDIT: DermNet
