When to Escalate HS Treatment Before Disease Turns Severe

In "When to Escalate HS Treatment Before Disease Turns Severe," the panel discusses how they sequence lifestyle counseling and decide when to escalate this patient's care.

Panelists differ on timing for lifestyle counseling. One raises smoking cessation at the first visit, given its impact on both HS and overall health, while deferring weight management to a later visit once trust is established; another brings up weight and diet only after a patient has come to trust them as their first true HS advocate. Cynthia Trickett instead screens for smoking through an intake questionnaire and frames quitting as functionally equivalent to adding a second biologic, given how inflammatory smoking is. She also raises gut health, probiotics, and reduced sugar early, and increasingly mentions GLP-1 receptor agonists at a first visit as part of a holistic approach, while pain, odor, and drainage remain her immediate focus. Dr. Tjahjono says he has shifted these conversations later in his career, since patients who have been blamed for their disease before may see early lifestyle counseling as one more rejection rather than support; he prioritizes credible patient resources over what he calls unreliable information online.

Turning to escalation, Dr. Tjahjono argues this patient, despite Hurley Stage 2 disease with limited tunneling, should be treated as needing systemic or biologic therapy given her failure of conventional antibiotics and significant functional impairment. The panel debates whether this patient counts as severe, several noting bluntly that if the case description alone conveys how much her disease has cost her, then it already is. They argue that gatekeeping advanced therapy behind Hurley Stage 2 or 3 is fundamentally backward, since the field's stated goal is intervening in that pre-moderate window before scarring becomes irreversible, much as dermatologists already treat scarring acne aggressively and early.

Our next episode, "Comparing Biologic Pathways and Screening for HS Comorbidities," has the panel comparing how they sequence biologic choice once TNF and IL-17 pathways are both on the table.