Emerging Therapies for Managing Hidradenitis Suppurativa in Patients With Skin of Color

The prevalence of patients diagnosed with hidradenitis suppurativa (HS) is significantly underestimated. Current literature estimates the prevalence of HS ranges from 0.1% to 4% of patients.1

However, Tiffany Mayo, MD, a board-certified dermatologist who specializes in treating patients with HS, said this estimate is inaccurate during her segment of a panel discussion titled “Hidradenitis Suppurativa: Emerging Therapies and Strategies for Effective Management” at the 2025 Skin of Color Update.2

Tiffany Mayo, MD, discusses emerging therapies used to treat hidradenitis suppurativa. | Image Credit: @JPC-PROD - stock.adobe.com .jpeg

Her presentation addressed current literature associating a higher prevalence of HS in females,3 and more specifically, African American women.1 The mean time until diagnosis can range anywhere between 7 and 10 years.

“Think about [having] this horrible, painful, stigmatizing condition for 10 years and not knowing what it is or why you have it,” Mayo said during her presentation.2 “Our goal is going to be, number 1, to increase time to diagnose it so that patients understand the condition that they have, and then increase access to treatment.”

Mayo explained that diagnosing patients with HS is simple. If a patient has had at least 2 boils in the last 6 months in any of the classic locations—the groin, breasts and under breasts, pubic area, armpits, and buttocks—the sensitivity is 90% and the specificity is 97% for a patient having HS.

“If we have a lower threshold for diagnosing [HS], we will change this time to diagnosis from 7 to 10 years to 1 year,” she said.

Addressing HS Stigma With Patients

HS is an inflammatory genetic condition, and there are associated comorbidities and external factors that may exacerbate the condition. Mayo emphasized the importance of educating patients with HS, addressing stigmas, and reframing the conversation so as not to place the blame on patients.

“I really want us to steer away from starting the conversation with a discussion about weight and from lifestyle things that put this burden of the disease and the reason for it on the patient,” Mayo said, “to more of [an understanding tone] that it is a complex, dynamic condition that requires a complex treatment approach.”

However, she added, it is still important to acknowledge comorbidities associated with HS. The most common comorbidities associated with HS are metabolic. In fact, Mayo noted that metabolic syndrome is seen in up to 50% of patients with HS, and there is an even greater prevalence of nonalcoholic fatty liver disease.

Mayo encouraged multispecialty collaboration as an advancement to patient care and management, given the overlapping metabolic comorbidities. Furthermore, she advised physicians to be diligent in educating their patients about HS and reducing stigmas as much as possible.

Managing and Treating Patients With HS

Mayo said the first step in treating this chronic inflammatory disease is setting realistic expectations for patients. And while there is no cure, there are therapies to help manage and treat symptoms and occasional flares.

Current guidelines published in the Journal of the European Academy of Dermatology and Venereology,4 which Mayo referenced during her discussion, don’t have one specific treatment for HS but rather a “consideration of approaches to assess and stack therapies based on the needs of the patient,” she said.

When deciding treatments for patients with HS, Mayo said she considers how the disease impacts patients and how to manage recurring flares during the treatment period. For patients with mild HS, while she may consult that patient on FDA-approved biologics, it’s standard practice to start with systemic nonbiologic therapies like tetracycline or doxycycline.2,4

Combination therapies such as clindamycin and rifampin, Mayo said, are the most heavily researched combination therapy for HS. Triple therapies that include rifampin also consist of moxifloxacin and metronidazole. Rifampin, when considered for treating female patients, has also been shown to interact with oral contraceptives, Mayo noted.2

“Ertapenem works fantastically,” Mayo said, highlighting another therapy that’s proven to be effective at treating HS. “However, we want to be good stewards, so this is not something that you're going to go for as a maintenance therapy, but for those patients who have more severe disease and are flaring, it can be a good option.”

The multiple therapies Mayo discussed ranged from hormonal therapies to oral contraceptives to antibiotics, all of which are effective at helping decrease HS flares. Yet again, she emphasized the importance of considering how HS impacts patients when deciding what therapy will work best for them.

Treating Special Cases of HS

During her discussion, Mayo described various cases of patients with HS. She explained that one patient agreed to a combination therapy of the oral antibiotic doxycycline and oral contraceptives. However, the patient had to stop doxycycline because she developed vaginal candidiasis but asserted her preference for oral therapies.

“The patient is letting us know that she prefers oral therapies. She's still more of a mild case, but what do we do next?” Mayo asked the audience. “Adjunct therapy. Again, there is no one treatment. It's going to be dynamic in the way that we treat patients.”

The next patient case Mayo described was a woman who’d been on and off oral antibiotics, but to no avail. She was also struggling to manage and contain her flares to the point where she had significant anxiety and HS was affecting her lifestyle.

“[At this point] we're beyond the intermittent antibiotics, right? We need something that's going to be prevented,” Mayo said. “We don't want to be chasing disease. We want to prevent it. What options do we have? Let's move on to our biologics.”

Before the first FDA-approved therapy used to treat HS, adalimumab, was available, Mayo said HS was managed primarily with various immunosuppressants and antibiotics.

Currently, there are multiple FDA-approved therapies used to treat HS. May mentioned 3 during her presentation; aside from adalimumab, she mentioned secukinumab and the most recently approved bimekizumab. All 3 biologics she referenced showed that at least 50% of patients were able to see a 50% reduction in abscess nodules.4

The third case Mayo presented was treating HS while the patient was pregnant. Some antibiotics are considered pregnancy category B, meaning there are no studies that show evidence of fetal harm. Metformin and zinc supplements are effective, which is why Mayo adds them to all of her patients’ regimens.4-6

Key Takeaways

Overall, Mayo’s discussion highlighted major gaps in diagnosis and addressed patient stigmas and comorbidities associated with HS, current adjuvant and combination therapies, and treatment strategies and approaches.

“I want you to think about saying these things to your patients,” Mayo said. “Let these words come out of your mouth. HS is not an infection. HS is not due to poor hygiene. Obesity is not the reason for HS. HS is not just a skin disease, and if you add HS is not your fault.”

References

1. Vinding GR, Miller IM, Zarchi K, Ibler KS, Ellervik C, Jemec GB. The prevalence of inverse recurrent suppuration: a population-based study of possible hidradenitis suppurativa. Br J Dermatol. 2014;170(4):884-889. doi:10.1111/bjd.12787

2. Mayo T. Hidradenitis suppurativa: emerging therapies and strategies for effective management. Presented at: Skin of Color Update; October 3-5, 2025; New York, NY.

3. Hidradenitis suppurativa (acne inversa): symptoms & treatments. Cleveland Clinic. September 11, 2025. Accessed October 14, 2025. https://my.clevelandclinic.org/health/diseases/17716-hidradenitis-suppurativa

4. Zoubloulis CC, Bechara FG, Benhadou V, et al. European S2K guidelines for hidradenitis suppurativa/acne inversa part 2: treatment. J Eur Acad Dermatol Venereol. 2025;39(5):889-941. doi:10.1111/jdv.20472

5. Alikhan A, Sayed C, Alavi A, et al. North American clinical management guidelines for hidradenitis suppurativa: a publication from the United States and Canadian Hidradenitis Suppurativa foundations. Part II: topical, intralesional, and systemic medical management. J Am Acad Dermatol. 2019;81(1):91-101. doi:10.1016/j.jaad.2019.02.068

6. Kromann CB, Deckers IE, Esmann S, Boer J, Prens EP, Jemec GB. Risk factors, clinical course, and long-term prognosis in hidradenitis suppurativa: a cross-sectional study. Br J Dermatol. 2014;171(4):819-24. doi:10.1111/bjd.13090