Diagnostic Delays and the Psychosocial Burden of HS

Welcome back to another Dermatology Times Case-Based Peer Perspectives series. In "Diagnostic Delays and the Psychosocial Burden of HS," moderator TJ Chao, MPAS, PA-C is joined by Laura Bush, DMSc, PA-C, DFAAPA to open the series on hidradenitis suppurativa.

TJ Chao introduces the panel and the disease focus: two patients with moderate to severe hidradenitis suppurativa (HS). He and Laura Bush frame the series around when clinical and psychological signals justify moving beyond conventional therapy. Dr. Bush identifies the first challenge as access. Many patients cycle through urgent care visits before ever reaching a dermatology provider who understands the disease. She names disease complexity, with its many layers of treatment, as the second major challenge. Chao adds that diagnosis can take seven to eight years, during which patients often see more than five medical providers before getting answers. Both note that patients today arrive better informed, thanks to the internet, social media, and increasingly artificial intelligence tools. Dr. Bush then details the psychosocial burden HS carries. Patients may face debilitating pain, miss work, skip social events, or withdraw from playing with their kids. She describes building trust first, giving patients a direct line to her nursing staff, and providing resources they can use between visits when something goes wrong. Chao shares that patients sometimes become reclusive because they cannot predict when the next flare will occur. Dr. Bush recalls a patient who showered eight times a day and another whose odor made daily life feel unbearable. Chao describes a patient whose flares became a recurring source of strain in his marriage. Dr. Bush then walks through HS pathophysiology in plain terms. A plugged, inflamed hair follicle eventually ruptures and releases inflammatory cytokines, including TNF-alpha, IL-1, IL-17, and IL-23, along with neutrophils. Repeated rupture can form tunnels and fibrotic scarring over time. As the disease progresses, functional impairment worsens alongside chronic inflammation, making catching and treating HS early, before scarring sets in, far easier than managing it once tunnels have formed.

The next episode in this series, "Biologic Mechanisms and When to Escalate Therapy in HS," turns to the growing armamentarium of HS biologics and when Dr. Laura Bush decides a patient needs more than conventional therapy.