Pain Management in Hidradenitis Suppurativa: Assessment, Acute and Chronic Treatment Approaches

Conclusions

• HS pain is a major, quality-of-life-limiting symptom that is often more impactful to patients than disease stage itself.
• Pain in hidradenitis suppurativa is frequently under-recognized and undertreated, so clinicians should routinely ask about it and measure it directly.
• Effective HS pain care should combine disease control with supportive pain management rather than treating inflammation alone.
• Patients benefit from distinguishing acute flare pain from chronic daily pain, because these require different treatment strategies and medication choices.
• Acute HS pain can often be managed with a stepped approach using compresses, acetaminophen, NSAIDs, suzetrigine, and only short, judicious opioid use when necessary.
• Suzetrigine appears to be a promising non-opioid option for moderate-to-severe acute pain because it provides analgesia without the addictive or respiratory risks of opioids.
• Rapid flare control with anti-inflammatory treatment, such as antibiotics plus corticosteroids in selected patients, can substantially reduce pain.
• Chronic HS pain is often mixed nociceptive, neuropathic, and nociplastic pain, which supports the use of neuropathic pain agents rather than relying on simple analgesics alone.
• Objective testing suggests that at least some HS lesions have neuropathic features, including altered sensation and reduced intraepidermal nerve fiber density.
• For chronic pain, options such as gabapentin, duloxetine, desipramine, and in refractory cases buprenorphine may improve suffering and function.
• Long-term conventional opioid therapy is generally a poor solution for chronic HS pain because of safety concerns and lack of durable benefit.
• Realistic treatment goals for chronic HS pain should focus on reducing suffering, improving function, and giving patients a usable flare plan rather than eliminating all pain entirely.