When Michael Rubio, PA-C, first began his career in dermatology nearly eight years ago, the complexity of hidradenitis suppurativa (HS) left him hesitant. The condition seemed too overwhelming, too systemic, and too unpredictable. “This isn’t something I treat,” he admits, recognizing that many healthcare providers share similar reservations. However, Rubio’s experience has taught him otherwise: HS is more common, more impactful, and more treatable than many realize. With the right approach, providers can make a significant difference in the lives of patients suffering from this often-misunderstood condition.
The Importance of Addressing HS
Hidradenitis suppurativa is far more than just painful bumps or abscesses. As Dr. Tiffany Mayo, MD, FAAD, of the University of Alabama at Birmingham, explains, HS is a “systemic inflammatory condition” that affects much more than the skin. The disease typically manifests as painful, recurring nodules and tunnels in areas like the underarms, groin, and buttocks. However, its impact extends beyond the skin, linking to metabolic disorders, rheumatologic conditions, gastrointestinal issues, and even psychological struggles.
When HS goes untreated, the toll on a patient’s physical, emotional, and social well-being can be severe. Depression, anxiety, missed work, and strained relationships are just a few of the consequences. Treating HS doesn’t just offer symptom relief—it provides a pathway for patients to reclaim their lives.
Overcoming Hesitation: Moving from Uncertainty to Action
Rubio understands why healthcare providers may hesitate to treat HS. The disease’s unpredictable nature can leave many unsure about how to proceed, especially when it comes to special populations like pregnant patients or children. “The question of how to treat HS in these cases remains open,” admits Dr. Mayo, acknowledging the complexities involved. However, Dr. Mayo is clear: not knowing everything shouldn’t lead to inaction. Early intervention, paired with adaptable treatment strategies, is the key to improving outcomes.
For example, although it can be tempting to avoid treating pregnant patients out of concern for safety, Dr. Mayo stresses that these patients deserve care too. “They’re suffering, too, and so we need to be equipped,” she said. With proper knowledge, healthcare providers can offer tailored solutions for a variety of scenarios. The goal is not perfection but progress.
Foundations of Treatment: Starting Small
The first step in treating HS is establishing a solid foundation with basic, non-invasive interventions. According to Dr. Mayo, “Every patient, regardless of their stage, should receive these topicals.” Benzoyl peroxide washes, topical clindamycin, and other antiseptics are essential tools in managing the condition. For patients with mild disease, antibiotics such as doxycycline or a combination of clindamycin and rifampin can help control flare-ups. Hormonal treatments like oral contraceptives or spironolactone can stabilize lesion counts, while metformin addresses both metabolic and inflammatory components.
These basic treatments, although simple, can offer significant relief and serve as a starting point for more advanced care.
When Systemic and Biologic Therapies Are Needed
For patients with frequent flare-ups or structural changes—such as the development of tunnels—topical treatments may no longer suffice. In these cases, systemic therapies, including biologics, become essential. Dr. Mayo highlights the importance of biologics, stating, “For patients who are constantly flaring, we need them on a biologic.” FDA-approved biologics like adalimumab, secukinumab, and bimekizumab have revolutionized HS treatment, providing long-term control for many patients.
While biologics were once seen as a last resort, they are now integral to the management of severe HS. And for patients in special populations—pregnant women or children—these therapies are often safe. For instance, TNF inhibitors like adalimumab are classified as pregnancy category B, indicating a lower risk than initially feared. Even pediatric patients can benefit from systemic therapies, tailored appropriately to their needs.
In-Office Procedures: Simple Yet Effective Interventions
Medications alone may not be enough to manage HS effectively. Simple in-office procedures can offer substantial relief for patients. Intralesional Kenalog injections, for example, can reduce inflammation during flare-ups, while deroofing minor tunnels can prevent the need for more invasive surgeries. Even laser hair removal has proven effective in reducing friction and inflammation in affected areas. As Dr. Mayo points out, “We can do simple procedures in clinic,” underscoring the importance of incorporating these interventions into daily practice.
Addressing Pain and Emotional Health
Pain is a central issue for many HS patients, and acknowledging this pain is crucial in building trust with patients. Dr. Mayo encourages healthcare providers to believe their patients when they report flare-ups, stating, “If a patient says they’re flaring, they’re flaring.” Pain management may involve anti-inflammatory treatments, procedural interventions, or adjustments to systemic therapies.
In addition to physical pain, emotional distress is also a significant concern for HS patients. Depression and anxiety are common, and referral to mental health professionals can greatly enhance overall care. A holistic approach to treatment—addressing both physical and emotional health—helps strengthen the provider-patient relationship and improves outcomes.
Building Confidence in Treatment
As Rubio reflects on his journey, he acknowledges that the wealth of information can feel overwhelming. “After hearing Dr. Mayo’s lecture, my head was buzzing with ideas, too,” he admits. But the key to building confidence lies in taking small, manageable steps. Start with a wash, try a short-term antibiotic, and introduce biologics for patients who need them most. With each step, providers gain confidence and improve patient outcomes.
Dr. Mayo’s central message is clear: “Early diagnosis and appropriate treatment is the key.” The path from feeling unsure to being confident in treating HS isn’t about knowing everything; it’s about being open to learning, taking action, and making a meaningful difference in patients’ lives.
Michael Rubio, PA-C, is a primary care physician assistant specializing in dermatology 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. He is also a co-founder of Well Revolution, a telemedicine-based direct primary care company.
Related topics
