Updated HS Guidelines Emphasize Biologics and Early Intervention

Updated treatment guidelines for hidradenitis suppurativa (HS) reflect an expanding therapeutic landscape, incorporating newly approved biologic therapies, emerging evidence for off-label treatments, and an increased emphasis on early intervention to prevent irreversible disease progression.

The recommendations, jointly supported by the HS Foundation and the American Academy of Dermatology (AAD), build on guidelines published in 2019 and aim to provide clinicians with updated evidence-based approaches to managing the chronic inflammatory skin condition.

In an interview with Dermatology Times, Haley Naik, MD, a dermatologist at the University of California, San Francisco, and president of the HS Foundation, discussed the clinical significance of the updated recommendations and their implications for treatment selection, disease monitoring, and patient access to care.

Expanding Treatment Options for HS

Since the publication of the previous guidelines in 2019, the US Food and Drug Administration (FDA) has approved 2 additional biologic therapies for HS: secukinumab (Cosentyx) and bimekizumab (Bimzelx). Their inclusion reflects the growing availability of targeted treatment options for patients with moderate to severe disease.

According to Naik, the updated recommendations also incorporate additional evidence supporting several off-label therapies, offering clinicians greater flexibility when developing individualized treatment plans.

The joint support of the HS Foundation and AAD represents another important development.

Naik explained that the previous guidelines were developed jointly by the US and Canadian HS foundations, whereas the updated recommendations have broader organizational backing. Beyond informing clinical decisions, the new guidelines are intended to help patients obtain access to necessary treatments.

Evaluating Biologic Efficacy and Treatment Recommendations

The guidelines address evidence supporting several biologic therapies, including adalimumab, secukinumab, bimekizumab, and infliximab.

Naik noted that Hidradenitis Suppurativa Clinical Response (HiSCR) 50 and HiSCR75 endpoints were used to evaluate treatment efficacy in phase 3 trials involving adalimumab, secukinumab, and bimekizumab.

Recommendations for infliximab, however, draw on a different evidence base, including historical clinical trials, more recent studies, and clinical experience supporting high-dose, high-frequency administration for HS management.

The updated guidelines also distinguish between strong and conditional recommendations, acknowledging that treatment decisions must account for the balance of clinical benefits, potential risks, treatment burden, and individual patient circumstances.

Conditional recommendations indicate that the most appropriate treatment approach may vary depending on disease characteristics, patient preferences, and other clinical considerations.

Similarly, conditional recommendations against certain therapies, including guselkumab, risankizumab, etanercept, and vilobelimab, indicate that these agents are generally not recommended for most patients but may be considered in select circumstances.

Emerging Evidence for Topical Treatments

Beyond systemic therapies, the guidelines address topical treatment options supported by clinical research.

Naik highlighted placebo-controlled trial evidence involving topical clindamycin, resorcinol, and ruxolitinib cream. Although these findings support their potential use in HS management, larger clinical trials are needed to strengthen the available evidence and inform future recommendations.

Additional phase 3 data evaluating topical ruxolitinib cream are anticipated in the coming year, potentially providing further insight into its role in HS treatment.

Tobacco Cessation and Treatment Response

The updated guidelines also conditionally recommend tobacco cessation as a strategy that may improve patients' responses to disease-directed therapies.

Naik emphasized that this recommendation should not be interpreted as evidence that tobacco cessation alone constitutes an effective treatment for HS.

Instead, the guidance reflects findings associating tobacco use with reduced therapeutic response to certain treatments. Additional research is needed to clarify the relationship between tobacco exposure, disease activity, and treatment outcomes.

Prioritizing Early Intervention to Prevent Irreversible Damage

A central message of the updated guidelines is the importance of recognizing HS early and initiating effective treatment before permanent tissue damage develops.

HS is a progressive inflammatory condition that can lead to draining tunnels, extensive scarring, and substantial physical and psychosocial burden. Once structural damage occurs, it cannot be fully reversed through medical treatment alone.

Naik emphasized that clinicians should routinely assess pain, provide adequate symptom management, and escalate treatment promptly when patients are not achieving sufficient disease control.

"I think what I would share is that HS is a progressive disease. Once tunnels and scarring have formed, that damage is irreversible," Naik told Dermatology Times.

With additional biologic therapies now available and strongly recommended in the updated guidance, Naik stressed that patients should not be subjected to prolonged periods of ineffective treatment before receiving appropriate therapeutic escalation.

Supporting Clinical Implementation

To help clinicians navigate the updated recommendations, the HS Foundation has developed HowTreatHS.com, an educational resource designed to support interpretation and clinical application of the guidelines.

The resource provides a centralized platform for understanding treatment recommendations and translating emerging evidence into individualized patient care.

Together, the updated recommendations underscore a shift toward earlier intervention, evidence-based therapeutic selection, and more proactive disease management, with the goal of improving long-term outcomes for individuals living with HS.