Martina J. Porter, MD, is a dermatologist at Beth Israel Deaconess Medical Center.

Martina Porter, MD

Panelists discuss how surgery plays a critical role in removing persistent draining sinus tunnels that don’t respond fully to anti-inflammatory medications, and explain their approach of combining biologics with surgical interventions rather than sequencing treatments, stacking therapies aggressively to achieve faster disease control.

Management Strategies in HS

Surgical management plays a crucial role in hidradenitis suppurativa (HS) treatment, particularly for patients with persistent draining tunnels (sinus tracts) that respond poorly to medical therapy alone. The surgical approach targets the distinct inflammatory environment within sinus tracts, which differs from other HS lesions and contains a mixed inflammatory cell population that medical treatments struggle to eliminate completely. For single draining tunnels, deroofing procedures work effectively, while patients with multiple interconnected tunnels and Hurley stage III disease benefit from carbon dioxide laser excision or standard surgical excision techniques.

Surgical outcomes demonstrate high patient satisfaction rates exceeding 90%, with recurrence rates at the surgical site remaining low at 4% to 6% when defined as requiring repeat surgery. However, practitioners emphasize that surgery addresses only existing lesions in treated areas and cannot prevent new disease activity in other locations. The optimal approach combines surgical removal of established draining tunnels with biologic therapy to control inflammation, stabilize disease, and reduce the risk of recurrence at surgical sites while preventing new lesion formation elsewhere.

Treatment sequencing involves a pack-and-stack approach for many patients, combining multiple therapeutic modalities simultaneously rather than waiting to see whether individual treatments work sequentially. This aggressive strategy aims to achieve functional disease control as quickly as possible, recognizing that patients have often suffered for years before receiving appropriate care. Practitioners counsel patients that achieving optimal disease control represents a journey requiring 3 to 6 months to a year, even with combination therapy, but emphasize the urgency of initiating comprehensive treatment while managing patient expectations about the timeline for improvement.

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Panelists discuss how treatment approaches vary by disease severity, with biologics becoming standard for patients with moderate to severe disease while milder cases receive antibiotics, hormonal therapies, and lifestyle interventions, emphasizing the need for flare management plans and patient education about treatment expectations.

Overview of Treatment Options in HS

Managing hidradenitis suppurativa (HS) requires a comprehensive, individualized approach that stratifies patients based on disease severity, progression risk, and quality of life impact. For patients with moderate to severe disease, biologics have become the cornerstone of treatment, with 3 FDA-approved options now available that offer substantial improvements in disease control. Even patients with milder disease but significant quality of life impact may benefit from biologic therapy, challenging traditional severity thresholds established for clinical trial enrollment that insurers have adopted as treatment criteria.

Treatment strategies for milder disease include antibiotic therapy, hormonal treatments, laser hair removal, nutritional counseling, and emerging options like GLP-1 agonists that address both HS symptoms and metabolic comorbidities. Practitioners emphasize the importance of early intervention with these approaches, particularly for patients with family history of HS, to potentially prevent disease progression. However, the lack of standardized protocols and outcome measures for mild disease represents a significant gap in clinical practice, leaving providers to rely on clinical experience and patient-reported improvements.

All patients require comprehensive counseling about potential disease flares and access to rescue treatments, including antibiotics for short-term use and options for urgent steroid injections for acute lesions. The management approach combines what patients are born with (genetic predisposition, immune function, wound healing capacity) and what they’re exposed to (environmental triggers, dietary factors), targeting multiple aspects of disease pathophysiology simultaneously. This holistic strategy recognizes that HS management extends beyond medication to include lifestyle modifications, surgical interventions, and ongoing supportive care tailored to individual patient needs and circumstances.

Panelists discuss how societal factors like embarrassment and limited health care access contribute to diagnostic delays of 6 to 7 years despite HS being clinically straightforward to identify and describe the profound impact on patients’ lives beyond sterile quality of life measures, including loss of relationships, careers, and life milestones.

Diagnostic Challenges in HS and Impact on Patient Quality of Life

Despite hidradenitis suppurativa (HS) being relatively straightforward to diagnose clinically, patients typically experience a delay of 6 to 7 years before receiving an accurate diagnosis. This delay persists due to multiple societal barriers rather than diagnostic complexity, including patient embarrassment about discussing symptoms in sensitive body areas, lack of awareness about the condition, limited access to dermatology specialists, and fragmented health care delivery. Many patients initially receive treatment for infectious abscesses without recognition of the underlying chronic inflammatory condition, leading to cycles of temporary improvement followed by recurrence.

The disease profoundly affects patients’ quality of life in ways that extend far beyond clinical measures, fundamentally disrupting their ability to pursue education, maintain employment, form intimate relationships, and plan families. Patients live with constant concerns about pain, drainage, odor, and the need for extensive bandaging, which can prevent them from participating in normal social activities and physical contact with loved ones. The psychological burden includes significant stigmatization and mental health challenges, with the disease often striking during critical life stages when individuals are establishing careers and relationships.

 represents an inadequate term for describing the devastating impact of HS, which truly represents a loss of life in terms of missed opportunities and experiences. The disease affects patients during their most productive years, preventing them from achieving personal and professional goals that contribute to a fulfilling life span. This recognition of the profound human cost of HS underscores the importance of early diagnosis and aggressive treatment to restore patients’ ability to participate fully in work, relationships, and family life.

Panelists discuss how HS develops from a combination of genetic predisposition and environmental exposures, leading to immune-based inflammation in skin folds, and explain clinical diagnosis methods, including Hurley staging and assessment of inflammatory lesions.

HS Pathophysiology, Diagnosis, and Classification

Hidradenitis suppurativa (HS) develops through a combination of genetic predisposition and environmental exposures, affecting approximately one-third of patients who have a family history of the condition. The disease involves multiple factors, including immune system dysfunction, metabolic influences, mechanical forces in body folds, and altered wound healing responses. Environmental triggers such as dietary factors, viral exposures, and other pollutants can activate the disease process in genetically susceptible individuals, often beginning during adolescence, when hormonal changes occur.

Diagnosis of HS relies primarily on clinical assessment, with practitioners identifying characteristic recurrent lesions in typical locations including the armpits, groin, under the breasts, and buttocks. The examination focuses on identifying inflammatory nodules, abscesses, and draining tunnels, along with signs like comedones, scarring, and discoloration in affected areas. While Hurley staging remains the standard classification system used in clinical trials to determine disease severity, clinicians also utilize outcome measures based on counting specific lesion types to assess treatment response.

Severity assessment extends beyond physical examination to include the substantial impact on patients’ daily functioning, including pain, drainage, odor, and mental health effects. Practitioners evaluate both the extent of tissue destruction and the disease’s effect on quality of life, recognizing that patients with limited physical disease may experience profound social and emotional consequences. This comprehensive approach considers the number of affected body regions, presence of new lesions in different locations, and the overall burden on the patient’s well-being when developing individualized treatment plans.

Martina Porter, MD

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