Please login or create an account. If you do not have access to this content, you will be shown a 30 second preview and licensing options.
- Presentation
Recognizing and Managing Hidradenitis Suppurativa in the Elderly Population
Description
The talk reviewed recognition and management of hidradenitis suppurativa (HS) in older adults, emphasizing that the aging population is growing and clinicians will increasingly encounter HS in patients with frailty, multimorbidity, and polypharmacy. Limited epidemiologic data suggest HS prevalence in the elderly is about 0.8%, with a narrower female-to-male ratio than in younger populations. HS may follow a bimodal onset pattern, but in older adults it can represent either persistent disease from earlier life or later-onset disease after age 60. Elderly patients may have more severe disease, higher inflammatory burden, and atypical distribution such as gluteal involvement, while also carrying a high comorbidity load including diabetes, COPD, renal disease, asthma, psoriasis, and other conditions. Treatment should be individualized and multimodal, balancing disease severity, quality of life, overall health, and medications. Topical therapies remain useful, though irritation may require reduced frequency. Systemic antibiotics require attention to renal/hepatic function and drug interactions; rifampin has major CYP interactions, clindamycin raises C. diff risk, fluoroquinolones and macrolides may affect QT, and doxycycline should be separated from calcium or iron supplements. Hormonal/metabolic options like finasteride, spironolactone, and metformin were discussed, with age-related hyperkalemia risk for spironolactone and renal limits for metformin. Biologics, including adalimumab, secukinumab, and bimekizumab, can be appropriate in moderate-to-severe elderly HS, with infection monitoring and vaccine counseling; IL-17 agents are preferred over TNF inhibitors in patients with significant heart failure or recent malignancy. Pain control is crucial: acetaminophen is preferred, NSAIDs should generally be avoided, and short-acting opioids may be used cautiously for refractory pain with constipation prophylaxis. The overall message was that aggressive, thoughtful, multidisciplinary care can improve symptoms and quality of life in elderly HS patients.
View moreConclusions
- Hidradenitis suppurativa does occur in older adults, though its prevalence is low, and the female predominance appears smaller than in younger populations.
- Elderly patients may present with later-onset disease and can have more severe and inflammatory HS than younger adults.
- HS in older adults may involve more atypical sites such as the gluteal region and less classic axillary or groin disease.
- Comorbidity burden is very high in elderly HS patients, making individualized and multidisciplinary care essential.
- Treatment in the elderly should be selected based on overall health, comorbid disease, concurrent medications, and patient goals rather than using a one-size-fits-all approach.
- Topical and systemic antibiotics remain useful, but renal/hepatic function, QT risk, C. difficile risk, and drug interactions must be considered carefully.
- Rifampin is often less attractive in older adults because of major CYP-mediated interactions, and clindamycin or fluoroquinolones require caution because of C. difficile risk.
- Hormonal and metabolic therapies can still be helpful, but spironolactone requires potassium monitoring and metformin is limited by renal function.
- Biologics are appropriate for moderate to severe HS in selected elderly patients and are not ruled out solely by age or kidney disease.
- Available evidence suggests biologics increase infection risk in older adults, but this risk should be balanced against disease severity and quality of life rather than used as an absolute contraindication.
- Vaccination status should be optimized before and during biologic therapy, while live vaccines should generally be avoided.
- Biologic choice should be guided by comorbidities, with IL-17 agents preferred over TNF-alpha inhibitors in patients with significant heart failure or recent malignancy.
- Pain control is critical in HS, and the safest approach in elderly patients is to control inflammation first while favoring acetaminophen and avoiding chronic NSAID use.
- Overall, older adults with HS can still be treated aggressively and effectively, with thoughtful monitoring to improve symptoms, pain, and quality of life.
- Van der Weijden DAY, et al. Br J Dermatol. 2023;190(1):105-113.
- Naik and Blum in JAMA Dermatology.
- Dagenet CB, et al. Am J Clin Dermatol. 2025;26(4):487-497.
- Caposiena Caro RD, Cannizzaro MV, Botti E, et al. J Am Acad Dermatol. 2019;80(5):1314-1321.
- Gordon D, et al. J Hosp Infect. 2016;92(2):173-177.
- Gregoire S, et al. J Am Acad Dermatol. Published online February 6, 2026;50190-9622(26)00172-6.
- Borrero NZ, Ananthakrishnan AN. Clin Gastroenterol Hepatol. 2019;17(9):1736-1743.e4.
- Chat VS, et al. J Am Acad Dermatol. 2024;90(6):1170-1181.
- Schofield P, Dunham M, Martin D, et al. Br J Pain. 2022;16(1):6-13.