Experts Highlight Earlier, Smarter HS Treatment Strategies

A recent Dermatology Times Case-Based Roundtable on hidradenitis suppurativa (HS), moderated by Steven Daveluy, MD, a board-certified dermatologist at Wayne State University in Detroit, Michigan, and board member of the HS Foundation, offered a rich exchange of clinical experience, emerging evidence, and candid reflections on the challenges of treating a complex inflammatory disease. The conversation created a space for clinicians to challenge entrenched habits, discuss new trends, and rethink how they approach severity, biologics, patient communication, and early intervention.

Reframing Severity: When Does HS Become “Moderate”?

A significant portion of the roundtable focused on the evolving understanding of HS severity. While Hurley staging remains widely used, attendees agreed that it often underestimates the burden of early disease. Pain, drainage, frequency of flares, and impact on daily life were considered just as important, if not more important, than the presence of tunnels.

Daveluy emphasized the need to shift clinical instincts toward earlier intervention, noting that attendees clearly recognized “earlier and more proactive treatment of hidradenitis suppurativa is needed.” He highlighted that many clinicians tend to wait for visible tunneling or extensive scarring before considering a biologic, even though meaningful disease progression may have already begun.

As he summarized the collective takeaway, “many dermatologists still wait for tunnel formation or Hurley Stage III disease before starting biologics,” despite mounting evidence that aggressive early therapy can prevent irreversible complications.

This recalibration of what counts as “moderate” HS had broad support from the group, especially given how quickly quality of life can deteriorate even with limited visible disease.

Early Use of Biologics and the Shift Toward Multimodal Care

One of the strongest themes of the evening was the recognition that, “HS is rarely controlled with a single treatment.” The group discussed biologics—secukinumab, bimekizumab, and adalimumab—not as last-line options, but as key components of multimodal regimens.

Participants referenced the BE HEARD, SUNSHINE/SUNRISE, and PIONEER trials while comparing real-world experiences with durability of response, dose intervals, and combination strategies. Many clinicians stressed that biologics need to be paired with antibiotics, procedural interventions, hormonal therapy, and lifestyle support, especially in the first year of care.

A lively exchange emerged around insurance hurdles and workflow barriers that prevent early biologic initiation. Several attendees admitted their treatment decisions are shaped more by system constraints than by clinical conviction—one of the most relatable and revealing moments of the night.

Emerging techniques, such as HS ultrasound for detecting subclinical tunnels, generated excitement, especially for their role in identifying patients who might benefit from earlier biologic escalation.

The Centrality of Patient Education and Patient-Reported Outcomes

Perhaps the most unifying message of the evening was the importance of patient education in HS care. Attendees repeatedly emphasized that misunderstandings about biologics, including risk perception, adverse event concerns, and treatment duration, delay appropriate care for many patients.

Daveluy underscored that clinical metrics aren’t the only important measures: “Patient-reported experience often matters more than lesion counts for decision-making.” This sentiment resonated deeply, especially as clinicians described how pain and drainage affect patients’ work, intimacy, confidence, and mental health.

There was wide agreement that patient-centered metrics—flare frequency, functional impairment, emotional burden—should drive decisions as much as IHS4 or Hurley staging. The group also discussed how forthright conversations early in care can prevent years of undertreatment.

Early Intervention for New Lesions: Avoiding the “Wait and See” Trap

Although not the largest portion of the program, discussion about new or seemingly mild lesions offered an important reminder: a single painful plaque may be the start of a more significant inflammatory process. Attendees agreed that early intralesional corticosteroids, short-term systemic therapy, or even earlier biologic escalation can prevent future tunnel formation.

This theme dovetailed with the evening’s broader emphasis on catching progression early—another form of proactive care that can change the course of disease.

The Value of Collaborative Clinical Dialogue

The roundtable closed with a strong sense of shared purpose. Daveluy’s own reflection captured the atmosphere perfectly: “I love getting the opportunity to talk to other dermatologists passionate about treating HS.”

Participants agreed that these conversations offer something uniquely valuabl: practical strategies, honest troubleshooting, and real-world insights that simply don’t fit into a lecture or journal article.

These events help clinicians validate their approaches, refine their decision-making, and feel less isolated in the face of insurance challenges, patient hesitations, and the complexity of applying clinical trial data to everyday practice.

Conclusion

The HS roundtable brought clarity to the evolving role of early biologic therapy, reinforced the importance of patient-centered decision-making, and reminded clinicians of the power of early, multimodal intervention. For dermatologists managing HS, whether a handful of patients or hundreds, this format offered an invaluable blend of evidence, experience, and practical wisdom.