AAD, HS Foundation Issue First Joint Hidradenitis Suppurativa Guidelines

The American Academy of Dermatology (AAD) and Hidradenitis Suppurativa Foundation (HSF) have issued their first joint guidelines of care for hidradenitis suppurativa (HS), with 37 evidence-based recommendations and strong support for 4 biologics in moderate to severe disease.^1,2

The guidelines, published online October 17, 2026, in the Journal of the American Academy of Dermatology, apply to adults, adolescents, and children aged 9 years and older.¹ The workgroup, co-chaired by Haley B. Naik, MD, MHSc, and Craig N. Burkhart, MD, MSBS, MPH, used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach and engaged patient partners on preferences and values.¹ The authors also state step therapy lacks evidence of clinical benefit in HS and is associated with treatment delays, reduced access to guideline-concordant care, and worse clinical outcomes.¹

"These guidelines establish an evidence-based standard of care for HS, giving patients, dermatologists, and payers a shared roadmap for what high-quality HS care looks like," said Haley B. Naik, MD, FAAD, co-chair of the Hidradenitis Suppurativa Guideline Work Group and president of HSF. "Every person living with HS deserves care that meets this standard."²

Biologic recommendations for moderate to severe hidradenitis suppurativa

The workgroup issued strong recommendations for adalimumab, bimekizumab, and secukinumab based on moderate certainty evidence, and for infliximab based on low certainty evidence.¹ Across 7 randomized controlled trials (RCTs) in 733 patients, adalimumab 40 mg weekly achieved Hidradenitis Suppurativa Clinical Response (HiSCR)50 at week 12 more often than placebo (risk ratio [RR], 1.92; 95% CI, 1.57–2.36).¹

In 3 RCTs including 784 participants, bimekizumab 320 mg every 2 weeks outperformed placebo at week 16 for HiSCR50 (RR, 1.67; 95% CI, 1.31–2.13) and HiSCR75 (RR, 2.14; 95% CI, 1.49–3.06).¹ Secukinumab 300 mg every 2 or 4 weeks improved HiSCR50 at week 16 versus placebo in 2 RCTs of 724 participants (RR, 1.35 for both regimens).¹ For infliximab, the authors cited large desirable effects, low potential risks, and unmet need in treatment-refractory disease, with the most favorable outcomes reported at 10 mg/kg every 4 weeks.¹

The panel conditionally recommended continuing adalimumab perioperatively and conditionally recommended upadacitinib for moderate to severe HS.¹ Conditional recommendations against etanercept, guselkumab, risankizumab, and vilobelimab reflect trials showing no significant benefit over placebo on primary efficacy measures.¹

Topical, antibiotic, procedural, and supportive HS recommendations

Conditional recommendations cover topical clindamycin, resorcinol, and ruxolitinib, each supported by low certainty evidence in mild to moderate disease.¹ In a phase 2 RCT, topical ruxolitinib 1.5% cream achieved HiSCR50 at 16 weeks in 79% of participants vs 50% with vehicle.¹ Doxycycline, tetracycline, clindamycin with rifampin, and intravenous ertapenem received conditional support, with ertapenem reserved for moderate to severe, typically refractory disease as a bridge to long-term therapy.¹

Spironolactone and short-term systemic corticosteroids also received conditional recommendations, while acitretin, isotretinoin, methotrexate, azathioprine, and avacopan drew conditional recommendations against use.¹ Methotrexate and azathioprine may still be used to prevent or manage antidrug antibodies in patients receiving tumor necrosis factor inhibitors.¹

Procedural options with conditional support include deroofing, incision and drainage, lesional or regional excision, laser hair removal, botulinum toxin, intralesional triamcinolone acetonide, and adjunctive hyperbaric oxygen therapy.¹ As good practice statements, the guidelines advise against radiotherapy in pediatric and adolescent patients and call for routine pain assessment as part of clinical evaluation.¹ Supportive pain management, tobacco cessation, oral zinc supplementation, and vitamin D repletion in deficient patients round out the conditional recommendations.¹

The workgroup found insufficient evidence to recommend GLP-1 or GLP-1/glucose-dependent insulinotropic polypeptide receptor agonists, specific diets, ustekinumab, and several other agents for HS treatment.¹ The authors called for head-to-head RCTs across biologic classes, noting 3 published network meta-analyses reached differing conclusions on relative HiSCR50 response rates.¹ They also flagged a need for outcome tools sensitive to mild disease and capable of capturing tunnel burden, an area of growing clinical focus.^1,3

References

1. Naik HB, Yeung H, Frazer-Green L, et al. Joint American Academy of Dermatology-Hidradenitis Suppurativa Foundation guidelines of care for the management of hidradenitis suppurativa. J Am Acad Dermatol. Published online October 17, 2026. https://doi.org/10.1016/j.jaad.2026.08.125

2. American Academy of Dermatology. First joint guidelines of care for hidradenitis suppurativa issued by American Academy of Dermatology and Hidradenitis Suppurativa Foundation. Published October 20, 2026. Accessed October 20, 2026. https://www.prnewswire.com/news-releases/first-joint-guidelines-of-care-for-hidradenitis-suppurativa-issued-by-american-academy-of-dermatology-and-hidradenitis-suppurativa-foundation-302914286.html

3. Dermatology Times. Q&A: Falk G. Bechara, MD, on long-term tunnel control and structural damage in HS. https://www.dermatologytimes.com/view/q-a-falk-g-bechara-md-on-long-term-tunnel-control-and-structural-damage-in-hs. Published October 14, 2026. Accessed October 20, 2026.