Julia Mhlaba Riley, MD, serves as an assistant professor at Northwestern University Feinberg School of Medicine and a dermatologist with Northwestern Medicine.

Julia M. Riley, MD

Palpation is essential for detecting HS inflammation when erythema is subtle in skin of color.

Delayed HS diagnosis among patients of color stems from patient, clinician, and system-level factors.

Keloid risk in HS and skin of color warrants procedural counseling and preventive strategies.

 in patients with skin of color requires careful palpation, attention to pigmentary clues, and deliberate efforts to address barriers to care, according to Julia Mhlaba Riley, MD, an assistant professor at Northwestern University Feinberg School of Medicine and a dermatologist with Northwestern Medicine.

Riley presented these clinical pearls during the Skin of Color Society session at the 

2026 European Academy of Dermatology and Venereology (EADV) Congress

 in Vienna, Austria. She touched on some of the key messages in a discussion with 

Tips for Recognizing Hidradenitis Suppurativa in Skin of Color, With Julia Riley, MD

, Riley noted HS is more prevalent among patients with skin of color, citing a 3-fold higher prevalence among Black patients in the United States. Her talk, titled "Hidradenitis suppurativa in skin of color: clinical pearls and practice considerations," addressed differences in clinical presentation, contributors to delayed diagnosis, and individualized approaches to treatment.

How Does HS Present Differently in Darker Skin Types?

Erythema may be subtle or absent in skin of color, Riley explained, with inflamed lesions often appearing hyperpigmented or brown. She recommended palpating the full area of involvement, including the axillae, groin, anogenital region, and any site showing scarring or hyperpigmentation, to assess for warmth, fluctuance, pain, and tenderness.

Identifying painful lesions allows clinicians to offer immediate relief, such as incision and drainage for an abscess or intralesional corticosteroid injection for an inflamed nodule. Riley added residual hyperpigmentation may signal poorly controlled disease in the past, an observation able to inform treatment decisions.

She also advised counseling patients to expect possible postinflammatory hyperpigmentation or hypopigmentation, including hypopigmentation following procedures such as deroofing.

What Contributes to Delayed HS Diagnosis in Patients of Color?

Riley described delayed diagnosis and undertreatment as multifactorial, spanning patient, clinician, and system-level factors. Shame and embarrassment can delay care-seeking, and patients who do seek care often present to emergency departments or urgent care settings rather than to dermatology.

She encouraged dermatologists to educate colleagues in emergency medicine, internal medicine, and obstetrics and gynecology on recognizing HS, including asking patients about other sites of involvement when evaluating a single lesion. At the system level, Riley pointed to insurance barriers and wait times of up to 6 months to see a dermatologist, delays during which HS can progress substantially.

Riley also highlighted medical mistrust and hesitancy toward biologic therapy among some patients. She recommended thorough education on the benefits and risks of treatment and an individualized approach to care.

How Should Clinicians Manage Pigmentation and Keloid Risk?

In Riley's experience, most patients prioritize control of active disease over pigmentary changes, although some are bothered by postinflammatory pigmentation and warrant direct discussion of these concerns. For hyperpigmented areas, she sometimes recommends a topical retinol.

Patients with HS and patients with skin of color both carry an increased risk of keloids, which may develop at inflamed HS sites without surgery or following deroofing and other procedures. Riley emphasized counseling patients on procedural risks and considering intralesional corticosteroids or intralesional 5-fluorouracil for treatment. When planning a procedure, prophylactic injection or postoperative radiation may help prevent keloid formation.

Looking ahead, Riley anticipates new HS medication approvals over the next few years will substantially change management, shifting the challenge toward selecting the best therapy for each patient. She urged clinicians to listen closely to patient concerns, stay informed on available options and their adverse effect profiles, and treat early to prevent further tissue destruction.

Editor's Note: This summary has been edited for grammar and clarity using artificial intelligence tools. Riley had no relevant disclosures of note.

Riley JM. Hidradenitis suppurativa in skin of color: clinical pearls and practice considerations. Presented at: Skin of Color Society (SOCS) session, 2026 European Academy of Dermatology and Venereology Congress; September 30, 2026; Vienna, Austria.

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At EADV 2026, Julia Mhlaba Riley, MD, discussed how hidradenitis suppurativa presents in skin of color and ways to close diagnostic and treatment gaps.

Julia M. Riley, MD

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