Hidradenitis suppurativa (HS) is a chronic, inflammatory skin condition characterized by recurring, painful, deep-seated nodules and abscesses. These lesions typically form in areas where skin rubs together, such as the armpits, groin, and under the breasts. Over time, inflammation can progress to form interconnecting tunnels beneath the skin, known as sinus tracts, leading to significant scarring. Managing HS requires a specialized and coordinated approach from multiple healthcare providers.
Initial Steps for Diagnosis and Care
A person’s first contact for HS symptoms is often their primary care physician (PCP) or general practitioner. The initial presentation, which includes boil-like lumps and tender bumps, is frequently misdiagnosed as simple acne, recurrent infections, or folliculitis. This diagnostic confusion contributes to a significant delay in receiving a correct diagnosis, often averaging around 7.7 years.
The PCP performs a preliminary screening, looking for classic diagnostic criteria: specific lesion types, typical location, and recurrence history. If HS is suspected, the PCP issues a referral to a specialist for definitive diagnosis and treatment planning. Early detection is important, as delayed diagnosis is associated with progression to more advanced stages of the disease.
The Specialist: Dermatologists and Medical Management
The dermatologist is the central figure in the long-term medical management of hidradenitis suppurativa. They possess the specialized knowledge required to stage the disease, most often using the Hurley staging system, which classifies severity based on the presence of abscesses, sinus tracts, and scarring. Based on this staging, the dermatologist develops a treatment plan ranging from topical therapies for mild cases to systemic medications for moderate-to-severe disease.
Medical management often involves courses of systemic antibiotics, such as clindamycin and rifampicin, administered over several months to reduce inflammation. Hormonal therapies and retinoids may also be considered.
For moderate-to-severe HS, biologics represent a significant advancement in therapy. These treatments target specific inflammatory pathways, such as tumor necrosis factor-alpha (TNF-α) or interleukin-17 (IL-17). Adalimumab, a TNF-α inhibitor, remains a primary choice for managing inflammation.
Newer options, including secukinumab and bimekizumab (targeting IL-17), are available for those who do not respond to initial therapy. Biologics are often used in combination with other agents to optimize outcomes, aiming to reduce flare-ups, prevent new scars, and improve quality of life.
Surgical Specialists and Procedural Treatment
When medical management is insufficient, or the disease has progressed to chronic tunnels and extensive scarring, surgical specialists become involved. These specialists include dermatologic surgeons, plastic surgeons, and general surgeons, who perform procedures tailored to the severity and location of the lesions.
One common minor procedure is incision and drainage, which provides temporary relief by draining an acute abscess. This method is not a long-term solution because the lesions almost always recur shortly afterward.
For recurring tunnels or nodules, a procedure called deroofing is frequently performed. Deroofing involves removing the “roof” of the sinus tract, allowing the base to heal from the inside out and significantly lowering the chance of recurrence compared to simple drainage.
For advanced disease, wide surgical excision is often the most effective approach. This major procedure involves removing the entire affected area to prevent future outbreaks. Following excision, the surgeon may close the wound using secondary intention (allowing it to heal on its own), a skin graft, or a tissue flap.
Integrating Care Through a Multidisciplinary Team
Managing HS requires a collaborative, multidisciplinary team because the condition extends beyond skin lesions and involves various associated comorbidities. This approach addresses conditions that often involve other organ systems and impact a patient’s overall health.
Specialists are needed to address the physical and mental health challenges of chronic HS:
- A rheumatologist manages inflammatory conditions linked to HS, such as spondyloarthritis.
- Pain management specialists develop strategies for sustained relief from painful flare-ups.
- Mental health professionals (psychologists and counselors) address common psychiatric comorbidities like anxiety, depression, and social isolation.
- Dietitians or nutritionists provide guidance, as HS is often associated with metabolic syndrome and obesity.
This holistic coordination ensures all aspects of the disease, from systemic health to mental well-being, are addressed.