Approach to Challenging Cases in HS

Hadar Lev-Tov, MD reframed the management of severe hidradenitis suppurativa (HS) by cautioning against the common “beginner error” of relying on single-agent therapy. HS is a multifactorial disease driven by follicular occlusion, rupture, chronic inflammation, and sinus tract formation, requiring clinicians to address multiple disease drivers simultaneously. Effective management often involves combination therapy that integrates medical treatments such as antibiotics, biologics, and hormonal agents with procedural interventions, intralesional steroids, antiseptic washes, and laser or surgical approaches to achieve meaningful disease control.

For patients with Hurley stage II or III disease, Dr Lev-Tov highlighted the role of specialized inpatient care to disrupt the vicious cycle of recurrent flares and emergency department visits. Data demonstrate that dermatology-led admissions significantly reduce length of stay compared with internal medicine services and facilitate earlier initiation of biologic therapy after discharge. He also stressed the importance of correctly defining disease flares, noting that true flares represent measurable increases in inflammatory lesions rather than slow or incomplete response to therapy, and emphasized setting realistic expectations and appropriate follow-up intervals early in care.

Procedural excellence was highlighted with deroofing as a tissue-sparing option for selected lesions, showing high patient satisfaction and durable non-recurrence rates. Additional considerations included addressing patient-driven dietary modifications, acknowledging limited HS-specific evidence, and incorporating clinical trial enrollment early in the treatment course. Dr Lev-Tov concluded that successful HS management requires coordinated, aggressive, and individualized care to achieve durable improvement in this challenging patient population.