FAQtual Insights: The HS Questions We Don’t Ask Out Loud

Hidradenitis Suppurativa (HS) is one of the most challenging chronic inflammatory skin conditions. It is unpredictable, painful, and psychologically devastating. Even experienced dermatology practicioners often face difficult decisions about when and how to escalate treatment. This FAQ addresses the questions clinicians navigate daily—and that patients often wonder about too.

When is it time to move beyond antibiotics?

Many patients with HS cycle through repeated courses of oral antibiotics. While antibiotics can reduce inflammation temporarily, they rarely change the disease’s long-term course. Clinicians typically consider escalating to biologic therapy when lesions recur despite adequate antibiotic trials, sinus tracts or tunnels begin forming, flares significantly impair daily life and quality of life, or Hurley stage progresses. Delaying escalation can lead to cumulative scarring and chronic tunnels, whereas early intervention may reduce long-term morbidity. For patients presenting with any tunnels or with multiple inflammatory nodules/abscesses, antibiotics can be utilized while starting a biologic, but treatment with a biologic should not be delayed, since preventing further tissue damage and tunnel formation is paramount.

How aggressive should treatment be early on?

Unlike psoriasis, HS does not follow predictable response curves. Early biologic therapy can reduce inflammation, slow/prevent tunnel formation, and improve pain and function. However, it is important to set realistic expectations. Complete remission can be challenging and require a combination of medical and surgical approaches, and treatment goals often focus on reducing flare frequency, minimizing drainage, and improving daily function. Clear communication early in the treatment process helps prevent frustration and therapeutic fatigue.

What counts as treatment success?

Success in HS management is not defined by dramatic visual clearance like PASI100 in psoriasis. One scarring and tissue damage have occurred, the skin won’t return to normal appearance, even when disease is controlled. It’s important to understand the roles of medical and surgical therapies to appropriately assess treatment success. Medical treatments target the inflammation in HS, so meaningful improvement is seen in fewer and shorter flares, prevention of new lesion formation, reduced erythema and drainage, improved mobility, and relief from pain. Absolute lesion counts are less important than functional restoration and quality of life measures. Pain and quality of life scales can provide a more accurate reflection of success than photographs of lesions.

When should surgery be considered?

Surgery becomes an important consideration when chronic draining tunnels persist despite systemic therapy, when extensive localized scarring develops, or when recurrent abscesses appear. While biologics can reduce inflammation, they cannot reverse fibrosis. Improvement with medical therapy can plateau when lesions that require surgery are present. Delaying surgical intervention can prolong pain and dysfunction, making procedures an essential part of effective HS management.

What if biologic therapy stops working?

Plateauing on biologics is common in HS. Clinicians may adjust dose intervals where supported by guidelines, use short-term adjunctive antibiotics to control flares, add to the medical regimen, inject intralesional corticosteroids for localized nodules, and reassess adherence and lifestyle triggers. Again, it’s important to understand the role of medical and surgical therapy. If a patient’s inflammation is under control, and they aren’t developing new lesions, and the plateau in therapy is due to chronic/persistent/recurrent lesions, then surgery must be undertaken to address those lesions. Adjusting medical therapy will not address lesions that require surgery. In cases of true nonresponse, switching to a different biologic may be helpful, but HS rarely behaves predictably, so expectations should remain grounded.

How does HS affect mental health?

HS carries a significant psychosocial burden. Patients often experience depression, social withdrawal, workplace impairment, and sexual dysfunction. Effective management is not solely about controlling inflammation—it is about restoring dignity, function, and quality of life. Screening for mental health conditions should be routine for all HS patients.

What is the reality of managing HS?

HS requires tolerance for imperfection and patience. There is no consistent “clear” endpoint, and progress is often nonlinear. Improvement is incremental, and disease control is often partial along the pathway to complete control. For experienced clinicians, successful HS management involves recognizing when escalation is necessary, setting honest expectations early, incorporating surgical techniques or collaborating with surgeons when necessary, and remaining persistent despite setbacks. Ultimately, expertise in HS is measured by complete disease control and restoring quality of life, which can be accomplished through combining medical and surgical therapies, but often requires a journey that is challenging for both patients and clinicians.