Hidradenitis Suppurativa: Phenotypes, Pitfalls, and Expanding Treatments
At Dermatology Week 2025, Mittal Patel-Cohen, MD, MPH, brought clarity and nuance to a complex condition in her session titled “Comprehensive Management of Hidradenitis Suppurativa (HS).” Dr Patel-Cohen laid out diagnostic pearls, comorbidity considerations, and an expansive update on both conventional and emerging therapies.
“We want to identify the presentations and complications of HS, understand its comorbid conditions, and develop better management strategies,” she opened, immediately acknowledging how often this chronic, inflammatory disease is missed. “The average delay in diagnosis can be over 10 years,” she warned, citing data showing that 63.7% of patients saw a physician 5 or more times before diagnosis.
She highlighted clinical patterns that often lead to misdiagnosis, especially in early or atypical presentations. HS may begin subtly, with a solitary lesion in the axilla or groin. But for more advanced or atypical cases, “we see it on thighs, the neck, and even the scalp—locations often mistaken for acne or boils,” she noted.
Dr Patel-Cohen emphasized phenotyping HS as a key to treatment planning. One model classifies patients by body habitus and lesion location, with Class 3 (female, axillary/groin, less severe) being the most common. “But don’t overlook the follicular vs inflammatory subtypes,” she added. “Follicular patients tend to respond better to acitretin, whereas inflammatory types often need systemic agents.”
Beyond the skin, HS is deeply entwined with comorbidities, ranging from polycystic ovary syndrome (PCOS) and metabolic syndrome to psychiatric conditions and spondyloarthritis. “Even if we’re not the ones managing these, we have to screen for them,” she urged, noting that patients with HS have higher rates of cardiovascular disease, inflammatory bowel disease, and depression.
From a therapeutic standpoint, Dr Patel-Cohen offered a toolbox ranging from topical zinc to systemic agents and biologics. She shared her own algorithmic approach: “I often combine spironolactone with metformin in my PCOS-type patients,” she said, while also highlighting the promise of glucagon-like peptide-1 receptor agonists for both HS and metabolic disease. Antibiotic regimens such as clindamycin/rifampin ± metronidazole remain staples, especially in combination.
On biologics, the field continues to grow. “Dupilumab opened the door for bullous pemphigoid, but for HS, we’re seeing options like adalimumab, infliximab, secukinumab, and now bimekizumab showing promise,” she said. In her practice, she often favors high-dose infliximab for refractory disease and sees better safety profiles with IL-17 agents.
Dr Patel-Cohen concluded with optimism: “We are seeing improvement, but not yet clearance, with most of our medications,” she said. “But there’s a robust pipeline. JAK inhibitors, IL-1 inhibitors, IL-36 inhibitors—they’re coming. And that’s exciting for our patients.”
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Reference
Patel-Cohen M. Comprehensive management of hidradenitis suppurativa. Presented at: Dermatology Week; October 22–25, 2025; Virtual.
