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Early Recognition and Comprehensive Care in HS: Expert Perspectives to Your Frequently Asked Questions

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Released: September 01, 2026

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Healthcare professionals managing hidradenitis suppurativa (HS) must weigh multiple moving parts at once, including disease severity; treatment stacking, dosing, and escalation; procedural needs and wound care; and patient expectations. Take home expert-informed strategies on identifying HS early via detailed physical examinations, distinguishing inadequate treatment response from persistent tunnels that call for a surgery referral, and structuring follow-up around a coordinated HS care plan that keeps pace with each patient's unique disease course.

Laura P. Bush
Laura P. Bush, DMSc, PA-C, DFAAPA
Hidradenitis Suppurativa Management FAQ

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Key Takeaways
  • Biologic therapy for HS may begin outside the dermatology setting when appropriate resources and follow-up are available, but complex or refractory disease warrants timely referral to a specialist.
  • Distinguishing inadequate treatment response vs needed procedural care for tunneling is essential to guide dose escalation and surgery referrals.
  • Durable HS control requires well-coordinated multidisciplinary care that addresses systemic disease, wound care, and patients' overall health (ie, comorbidities, psychosocial needs).

In this commentary, Laura P. Bush, DMSc, PA-C, DFAAPA, answers questions posed by healthcare professionals (HCPs) during a live symposium titled “Stepping Up in HS: Essential Skills for Early Recognition and Treatment to Relieve the Burden of Disease.” Learn about specific considerations for recognizing hidradenitis suppurativa (HS) features early, optimizing biologic therapy, and coordinating comprehensive, multidisciplinary care for patients.

Are there any early physical findings that are commonly missed in patients with mild or early-stage HS?
Several subtle findings can point to early or mild disease and are easily overlooked in routine skin examinations. These include deep, tender nodules that sometimes require palpation to detect; double-headed comedones; and recurrent lesions in characteristic, intertriginous sites like the axillae, groin, inframammary folds, and perineal, perianal, or gluteal areas. Early scarring or subtle textural change of the skin are other physical features of HS that can be assessed, while palpating for induration, fibrotic areas, or tethering is useful when there are no active abscesses present. Some patients might present with a small draining opening, which can represent a more established tract underneath the visible surface. Finally, focal hyperpigmentation or erythema at prior lesion sites can provide evidence of recurrent inflammation that might otherwise be missed during physical inspection.

What monitoring strategies do you employ for patients who need treatment escalation, referral, and wound care support all at the same time?
Rather than treating these as separate problems, it is more effective to approach patients’ HS care with a single, coordinated plan. During these visits, HCPs should comprehensively document patients’ disease activity, including lesion count and location, the presence of draining tunnels, any pain that is directly associated with HS, and flare-up frequency per month. HCPs should also capture the disease’s impact on mobility, ability to work, sleep, and overall quality of life, photographing representative areas when appropriate. Establishing a baseline measure of severity via the Hurley stage system, ISH4, or HiSCR gives the larger healthcare team a consistent reference point for tracking patients’ treatment response and determining whether dose escalation is warranted.

In addition, any wounds should be assessed during the same visit, with particular attention paid to drainage volume, odor, maceration, pain, and dressing needs. Referrals should also be made strategically, ideally with 1 clear point of coordination rather than several disconnected pathways. That said, dermatology HCPs or HS specialists are best positioned to manage biologic therapy, other pharmacotherapy needs, and deroofing procedures. In turn, wound care referrals support patient education, dressing selection, supplies needed, and an at-home care plan. Surgical referrals are then appropriate for persistent tunnels, localized refractory disease, or extensive Hurley stage III HS where deroofing or excision is beneficial. Finally, referrals to primary care and other relevant specialties, such as gastroenterology, endocrinology, or psychiatry, should be considered for associated comorbidities as part of the whole patient’s care plan.

Patients with HS who are candidates for biologic therapy may live in regions with limited access to specialized dermatologic care. In these cases, can biologic therapies be prescribed in the urgent care setting?
If the urgent care setting has the resources to prescribe and appropriately follow patients with HS, there is no inherent reason why biologic therapies could not be initiated, although doing so can be operationally challenging. It often is more practical to use the urgent care visit to refer to dermatology or an HS specialist, so patients can access their expertise and advanced therapy as needed.

Regardless, HCPs in the urgent care setting can order the necessary labs and should help coordinate care with dermatology. Furthermore, managing the necessary paperwork to obtain a biologic therapy for HS, whether a prior authorization or copay assistance program is needed, can be difficult to do in the urgent care setting. Because denials for biologic therapies are commonplace, the HS Foundation offers templates for prior authorizations, including letters of medical necessity and denial appeals, to submit for on- and off-label use and dose escalations. These resources are easy to use and meaningfully shorten the time needed to submit the necessary paperwork to help patients access their much-needed treatment.

What screening and monitoring strategies do you use before and after starting patients with HS on a biologic therapy?
The specific workup for each patient depends on the selected biologic therapy. A practical pretreatment approach includes reviewing patients’ history of serious or recurrent infections, performing tuberculosis risk assessment and testing, and screening for hepatitis B, with hepatitis C and HIV testing considered based on individual risk factors. I also assess patients’ vaccination status and provide any updated age-appropriate nonlive vaccines as needed. As for baseline labs, HCPs should order a complete blood count, comprehensive metabolic panel, and any specific tests as indicated in the therapy’s prescribing information. For patients with comorbidities, HCPs must review concomitant medications as well.

As previously mentioned, HCPs should also establish disease severity with a staging tool and document this alongside any physical and psychosocial findings in the health record. Then there are pregnancy considerations that must be reviewed with applicable patients, and those who are considering an IL-17 inhibitor should be screened for a history of inflammatory bowel disease. Further review can be done to document patients’ history or risk of malignancy, demyelinating disease, heart failure, and other class-specific contraindications or precautions. At the same time, HCPs should consider relevant comorbidities more broadly before selecting treatment.

After initiating a biologic therapy, follow-up visits provide the opportunity to assess both treatment efficacy and tolerability. To determine efficacy, patients with a good response generally present with fewer new nodules, abscesses, or flare-ups; less drainage; reduced pain; improved function and quality of life; and stable or decreased tunnels. In determining tolerability, attention should be paid to infections and injection-site reactions. New gastrointestinal adverse events, particularly with IL-17 inhibitors, as well as neurologic or other class-specific adverse events should also be assessed. Repeat labs are usually reserved for when clinically indicated or per the specific therapy. These may be limited to tuberculosis testing alone or expanded to include a complete blood count, comprehensive metabolic panel, and lipids.

For patients who just started a biologic therapy, how do you discuss treatment timelines with them?
Patients benefit from a clear, honest framework for what to expect. Although biologic therapies reduce the inflammation that drives HS, this process takes time and does not immediately erase existing tunnels or scars. Patients may notice less pain or fewer new lesions within the first several weeks or months of treatment, and flare-ups should become less frequent over time. As I mentioned, treatment success is typically measured over a longer period, often in the range of 4-6 months. Framing this as a shared journey, where patients know that you are there for them, helps build trust and communication that ultimately supports treatment adherence and positive long-term outcomes.

How can HCPs distinguish between an inadequate response to biologic therapy that warrants a change in treatment vs persistent tunnels or nodules that require procedural/surgical management?
In the process of evaluating patients’ response to biologic therapy, they should first be given adequate time on the therapy (ie, 4-6 months). During this period, the development of new lesions ideally should slow or stop entirely.

In cases involving deeper scarring and tunnels, resolution of HS may be challenging to achieve with pharmacotherapy alone. Therefore, patients with otherwise well-controlled disease aside from 1 persistent tunnel are often great candidates for deroofing or excision rather than changing the systemic therapy altogether.

For patients with a partial response to biologic therapy—for example, they have roughly 70% improvement but still experience flare-ups—dose escalation may be considered before or alongside surgical intervention. This might include escalating adalimumab 80 mg from biweekly to weekly dosing or secukinumab 300 mg from monthly to biweekly dosing. Both examples are available via prior authorization templates from the HS Foundation, which can help streamline the approval process.

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