Derm on Air: Recognizing HS Early, From Diagnosis to Disease Burden

Hidradenitis suppurativa (HS) goes undiagnosed for about 7 years on average worldwide. Many patients cycle through urgent care, incision and drainage, and repeated antibiotic courses before anyone names the disease. Earlier recognition depends on reframing recurrent boils in skin folds as a chronic inflammatory condition rather than an infection.

The debut episode of Derm on Air, a Dermatology Times series, is focused on advancing HS care from diagnosis to treatment selection, took up this problem. Host Cynthia Trickett, MPAS, PA-C, of Forefront Dermatology in Dallas, Texas, spoke with Leigh Ann Pansch, MSN, FNP-BC, DCNP, a dermatology nurse practitioner in Cincinnati, Ohio.

Location remains the central diagnostic clue. HS, also called acne inversa, favors inverse sites including the ear creases, posterior neck, axillae, inframammary folds, abdominal folds, anterior groin, and gluteal cleft. Any recurrent painful nodule, draining lesion, or scar in a fold warrants a working diagnosis of HS until proven otherwise, with scars counted alongside active lesions as evidence of disease history.

History sharpens suspicion further. A personal or family history of HS, or of autoimmune disease such as thyroid disease, psoriasis, or lupus, should raise the index of suspicion. Many patients also follow a bimodal course, with onset near puberty and renewed activity around perimenopause.

Comorbidity screening belongs in the initial workup. North American guidelines support evaluating patients with HS for inflammatory bowel disease, spondyloarthropathy, and polycystic ovary syndrome (PCOS), among other associated conditions.² Targeted questions about nocturnal diarrhea, stiffness after rest, and menstrual regularity can surface each one efficiently.

Quality-of-life impact should shape severity assessment from the first visit. A single axillary lesion preventing a patient from lowering the arm is not mild disease, regardless of lesion count. Asking patients to rate their own burden as mild, moderate, or severe, then documenting their reasoning in their own words, anchors this assessment.

Relationship building also matters for a population passed between clinicians for years. With permission, clinicians should ask about effects on intimacy, a domain dermatology visits rarely address. Counseling on weight and smoking can wait until trust forms, since neither change predictably resolves disease.

For APPs in urgent care, primary care, and dermatology, the core message is to treat HS as an inflammatory rather than infectious disease. Adopting this framing, and referring patients to clinicians experienced in HS, positions them for evidence-based management before scarring accumulates.

References

1. Saunte DM, Boer J, Stratigos A, et al. Diagnostic delay in hidradenitis suppurativa is a global problem. Br J Dermatol. 2015;173(6):1546-1549. doi:10.1111/bjd.14038
2. Alikhan A, Sayed C, Alavi A, et al. North American clinical management guidelines for hidradenitis suppurativa: a publication from the United States and Canadian Hidradenitis Suppurativa Foundations: part I: diagnosis, evaluation, and the use of complementary and procedural management. J Am Acad Dermatol. 2019;81(1):76-90. doi:10.1016/j.jaad.2019.02.067