Dr. Charrow Highlights Earlier Biologic Use and Deroofing in Hidradenitis Suppurativa

As treatment options for hidradenitis suppurativa (HS) continue to expand, clinicians should consider both biologic therapies and procedural interventions as part of individualized disease management, according to Alexandra Charrow, MD, in an interview with Dermatology Times at Maui Derm NP+PA Fall 2026.

During the meeting, Charrow discussed 2 major aspects of HS management: identifying patients with moderate to severe disease who may benefit from biologic therapy and increasing clinician comfort with surgical procedures, particularly deroofing. She also highlighted ongoing challenges surrounding treatment selection after biologic failure and emerging research that could eventually allow clinicians to better match individual patients with therapies.

Rethinking When to Consider Biologics

One of Charrow’s central messages was the importance of recognizing moderate to severe HS and considering when systemic treatment may be warranted.

Rather than relying solely on traditional staging, clinicians can consider a patient’s overall inflammatory burden, including inflammatory nodules, abscesses, and draining tunnels. For patients with substantial inflammatory disease who do not respond adequately to nonbiologic treatment, such as antibiotics or spironolactone, biologic therapy may represent an appropriate next step.

The expanding number of biologic therapies available or under investigation is creating additional options for patients with HS. However, Charrow noted that the growing treatment landscape also raises a more difficult clinical question: what should clinicians do when the first biologic does not work?

Treatment failure can be challenging for both clinicians and patients, particularly when patients begin biologic therapy expecting significant improvement. Clinicians must then determine which treatment to try next and whether other interventions should be incorporated into the management plan.

Currently, there are limited data to reliably predict which therapy will work best for an individual patient. Charrow highlighted research into patient endotypes and biomarkers as a potential way to address that gap.

Greater understanding of these factors could eventually help clinicians identify which medication a patient is most likely to respond to—or potentially experience an adverse reaction from—before treatment is initiated.

Bringing Deroofing Into Dermatology Practice

Another major focus of Charrow’s discussion was procedural management, particularly encouraging clinicians to become more comfortable incorporating deroofing into HS care.

Charrow explained that dermatology clinicians who already perform excisions may possess many of the skills and tools necessary to begin performing deroofing. Although the techniques differ, existing familiarity with dermatologic surgery can provide a foundation for incorporating the procedure into practice.

A key goal of the Maui Derm session was therefore to provide clinicians with practical information about identifying appropriate candidates, discussing the procedure with patients, and determining how deroofing could fit into their clinical practice.

“I hope people are slightly more empowered to do deroofing or other kinds of surgical interventions for patients with hidradenitis,” Charrow told Dermatology Times.

For clinicians who have not previously performed the procedure, selecting an appropriate first patient and lesion may be particularly important. Charrow discussed factors clinicians can consider when identifying candidates and emphasized making procedural management a more accessible component of HS care.

Looking Beyond Traditional Procedures

Charrow also highlighted emerging procedural approaches that could eventually expand treatment options for patients with HS.

Although much of the recent attention in HS has focused on the growing biologic pipeline, Charrow said she is particularly interested in research evaluating nonsurgical procedural approaches.

Investigators are exploring interventions that involve injecting substances directly into HS tunnels, including intralesional hypertonic saline as well as antimicrobial and astringent agents.

These approaches remain areas of ongoing investigation but represent another potential direction for HS management as researchers explore strategies beyond systemic medication and traditional surgery.

Navigating Treatment After Biologic Failure

The expanding treatment landscape also creates new challenges for dermatology nurse practitioners and physician assistants caring for patients with HS.

Charrow noted that APPs have become increasingly comfortable prescribing biologics and initiating biologic treatment. The more difficult clinical question may arise when a patient does not achieve an adequate response to that first therapy.

Without established biomarkers to guide treatment selection, clinicians currently rely on available evidence and individual patient characteristics when choosing subsequent therapies.

Comorbidities are among the factors that can help inform treatment selection. However, a greater understanding of HS endotypes could eventually allow clinicians to make these decisions with greater precision.

Research into biomarkers may ultimately help answer a question that remains central to HS management: which treatment is most likely to work for which patient?

Translating Maui Derm Takeaways Into Practice

Beyond HS, Charrow highlighted several additional areas of interest from Maui Derm NP+PA Fall 2026.

She pointed to discussions surrounding chronic urticaria and its evolving treatment landscape, as well as infectious disease management. Charrow specifically highlighted discussion of spinosad for scabies amid concerns about resistance to some existing treatments. She also noted a session focused on connective tissue diseases as another standout from the meeting.

Still, her primary message for clinicians treating HS centered on translating evolving treatment options into practical changes in patient care.

Charrow said she hoped attendees would leave the meeting more confident in recognizing patients who may be appropriate candidates for biologic treatment and in considering deroofing and other procedural interventions as part of comprehensive HS management.

As the therapeutic landscape continues to expand, HS management may increasingly require an individualized approach that incorporates both systemic therapies and procedural interventions while researchers work toward more precise methods of matching patients with the treatments most likely to benefit them.

References

1. Charrow, A., Santiago-Soltero, K., & Porter, M. (2024). Biologics in hidradenitis suppurativa: Progress and new directions. Journal of the American Academy of Dermatology, 91(6 Suppl), S27–S30. https://doi.org/10.1016/j.jaad.2024.09.027
2. Vu, T. T., Soong, L. C., Hagtvedt, R., & Keeling, C. P. (2025). Surgical deroofing in the management of hidradenitis suppurativa alone or as an adjunct to medical therapies. Dermatologic Surgery, 51(7), e17–e21. https://doi.org/10.1097/DSS.0000000000004604
3. Frew, J. W., Marzano, A. V., Wolk, K., Join-Lambert, O., Alavi, A., Lowes, M. A., Piguet, V., Thorlacius, L., Shalom, G., Egeberg, A., Kirby, J. S., Ingram, J. R., Jemec, G. B. E., & Zouboulis, C. C. (2022). Identification of biomarkers and critical evaluation of biomarker validation in hidradenitis suppurativa: A systematic review. JAMA Dermatology, 158(3), 300–313.