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Presentation

Hidradenitis Suppurativa Management Update: Shared Decision-Making, Topicals, Hormonal and Antibiotic Approaches, and Flare Plans

Description

The speaker outlined an updated, practical approach to hidradenitis suppurativa (HS) management centered on shared decision-making and individualized treatment menus rather than rigid algorithms. They emphasized using validated quality-of-life assessment to guide escalation, since HS severity and patient burden often do not match. Topical therapy has become more useful in practice, especially resorcinol for both maintenance and flares, while topical clindamycin has limited benefit and should be paired with a broad-spectrum wash to reduce resistance; newer topical options such as clascoterone and ruxolitinib may be promising. The speaker also highlighted hormonal and metabolic drivers, recommending attention to contraceptives, PCOS features, menstrual flares, and use of spironolactone as a mainstay in women, with finasteride as an alternative in selected patients. Metformin was described as less impressive, whereas GLP-1 agents were viewed more favorably for HS, especially in patients with obesity or diabetes. Oral antibiotics still have a role, but clindamycin-rifampin is being used less often; clindamycin alone, doxycycline, amoxicillin-clavulanate plus prednisone for flares, and pregnancy-safe options like cephalexin were discussed. Retinoids, dapsone, and intralesional steroids have more limited roles. A key recommendation was to give every patient a flare plan, often including an antibiotic, resorcinol, and possibly a prednisone taper, to reduce urgent visits and emergency care.

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Conclusions

HS treatment should be individualized using shared decision-making rather than a one-size-fits-all algorithm.
Validated patient-reported quality of life measures are useful for deciding when to escalate HS therapy.
Topical therapies, especially resorcinol 15%, can be effective for both maintenance and flares in mild to moderate HS.
Clascoterone and topical ruxolitinib appear promising as emerging topical options for HS maintenance.
Evaluating hormonal drivers such as PCOS, menstrual flares, and androgenic contraceptives is important because anti-androgen approaches often work better than antibiotics in appropriate patients.
Spironolactone is a practical first-line hormonal option for many female patients, while finasteride can be an alternative in selected cases.
Metformin has limited and inconsistent benefit for HS, despite usefulness for metabolic comorbidities.
GLP-1 receptor agonists may offer meaningful benefit in HS and could have future preventive value, especially in patients with diabetes or obesity.
Oral antibiotics still have a role, but they are being used more selectively and clindamycin-rifampin may be less favorable than clindamycin alone in some cases.
Antibiotic benefit in HS may partly reflect effects on microbial dysbiosis rather than simple infection control.
Retinoids are not broadly effective for HS, but acitretin may help a follicular phenotype.
Prednisone can be very effective for short-term flare control, but it should be used carefully and ideally within a broader flare plan.
A written flare plan is highly valuable for reducing urgent visits and helping patients manage exacerbations promptly at home.

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