How Understanding of HS Has Evolved in Clinical Practice

Welcome back to another Dermatology Times Clinical Case Collective series. In "How Understanding of HS Has Evolved in Clinical Practice," moderator Michael Payette, MD, MBA, FAAD is joined by Ahuva Cices, MD, FAAD, Leonardo Tjahjono, MD, FAAD, and Cynthia Trickett, MPAS, PA-C to open the series on hidradenitis suppurativa (HS).

The panel opens by tracing how their thinking on HS has shifted over the past decade. They agree understanding has deepened well beyond a purely dermatologic view. HS is now recognized as a systemic inflammatory disease involving skin, adipose tissue, and circulating immune cells, not an isolated skin condition. That broader framing has pushed the field toward earlier, more aggressive treatment instead of the older pattern of waiting to see how disease progressed before intervening.

The panelists debate whether HS has actually become more common or whether clinicians are simply recognizing it more often. One view holds that increased awareness, not rising incidence, explains more diagnoses, pointing to the disease's history as an under-recognized, frequently misdiagnosed condition before dedicated therapy existed. Another panelist pushes back, arguing that awareness alone doesn't fully explain what they're seeing; environmental factors and a broader rise in autoimmune and auto-inflammatory disease may also be contributing to genuine increases in prevalence.

A persistent obstacle, the group notes, is that many patients never reach a dermatologist at all. They describe patients cycling through primary care and urgent care visits, where painful nodules are labeled as infected cysts or boils rather than flagged as HS. Outreach to OB-GYN clinics, urgent care centers, and family medicine has helped shorten that path to referral in some practices. The panel cites community prevalence estimates ranging from 0.1% to 4%, a range that could place HS ahead of psoriasis. They point to the approval of the first dedicated biologic therapy in 2015 as a turning point, since prior options were limited to antibiotics, surgery, and older immunosuppressants like cyclosporine and methotrexate that rarely worked well.

Our next episode, "Defining HS Severity: Staging Systems and Standard of Care," has the panel defining exactly what mild, moderate, and severe HS look like in practice.