Navigating Pediatric Hidradenitis Suppurativa: A Q&A on Early Diagnosis and Effective Treatment

Robyn Guo Ku, BS, a medical student; Tarannum Jaleel, MD, MS; and Daniela Kroshinsky, MD, MPH, of Duke University School of Medicine.

Hidradenitis suppurativa in pediatric patients can present challenges from delayed diagnosis and resulting anxiety because of the symptoms of the disease. At the Society for Pediatric Dermatology Annual Meeting, Robyn Guo Ku, BS, a medical student at the Duke University School of Medicine, presented on the development of an educational module to raise awareness of and destigmatize hidradenitis suppurativa among children, as well as the results of a study on drug survival of adalimumab and infliximab in pediatric patients with hidradenitis suppurativa.1,2

Here, Guo and her colleagues Tarannum Jaleel, MD, MS, and Daniela Kroshinsky, MD, MPH, of the Department of Dermatology at the Duke University School of Medicine, answered questions via email related to these presentations.

These answers have been edited for style and clarity.

The American Journal of Managed Care® (AJMC®): What are the challenges of diagnosing hidradenitis suppurativa in a pediatric population? What factors contribute to diagnostic delays in hidradenitis suppurativa?

The average diagnostic delay for hidradenitis suppurativa is 10 years. When symptoms first begin, hidradenitis suppurativa lesions are frequently misdiagnosed as other cutaneous diseases such as acne, folliculitis, ingrown hairs, abscesses, and cellulitis. Some factors that contribute to diagnostic delays include a lack of awareness of hidradenitis suppurativa among both patients and health care professionals, long wait times to see pediatric dermatology, and a reluctance to seek medical care due to the stigma surrounding hidradenitis suppurativa and its involvement of the sensitive areas of the body.

AJMC: What are the core signs and symptoms of hidradenitis suppurativa that you are teaching children to identify in themselves or others? How do you balance providing enough information for identification without causing undue anxiety?

The core signs and symptoms we want to emphasize are recurrent painful lumps under the skin in areas where the skin can rub together (under the breasts, under the armpits, around the buttocks, where your legs meet your body, and the lower abdomen/pubic region). These lumps can drain pus and leave scars.

We want to provide children with an introduction to hidradenitis suppurativa to increase awareness of this disease and address misconceptions about hidradenitis suppurativa. We would especially like to emphasize that hidradenitis suppurativa is not contagious and that it is not caused by a lack of personal hygiene.

AJMC: Your finding that adalimumab survival is superior to infliximab survival in pediatric patients with hidradenitis suppurativa contrasts with past research that has found the opposite in adult patients with hidradenitis suppurativa. Can you go through some of the reasons for this difference?

A study in 2021 conducted by Trotta et al that compared the development of antidrug antibodies to infliximab and adalimumab in adult and pediatric patients with rheumatologic conditions (ie, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, juvenile idiopathic arthritis, Crohn disease, ulcerative colitis) found that pediatric patients developed antidrug antibodies to infliximab earlier than adult patients.3 The development of earlier antidrug antibodies to infliximab may be one of the reasons for the difference we observed. Additional research is needed regarding the development of antidrug antibodies to biologic therapies in patients with hidradenitis suppurativa.

AJMC: Your study clearly demonstrates that biologic survival is significantly higher in biologic-naïve pediatric patients with hidradenitis suppurativa compared with those who are biologic nonnaïve. Beyond the general expectation that patients new to biologics might respond better, are there particular reasons or underlying disease characteristics that could explain this difference in drug survival?

The development of antidrug antibodies to TNF-α inhibitors like adalimumab and infliximab can diminish the efficacy of these biologic therapies when patients discontinue and reinitiate them. Physicians will try to combat the development of anti-drug antibodies by prescribing methotrexate to be used concurrently with TNF-α inhibitors. This underscores the importance of sustained insurance coverage for these medications and access to timely dermatologic care.

Additionally, when patients are switched from one biologic to another, it may be because the first biologic did not adequately control their disease due to their disease extent. Gluteal involvement was associated with lower drug survival in our study. Patients’ disease progression and severity may also diminish the efficacy of any biologics initiated thereafter.

AJMC: Based on the data presented in your poster, what are some actionable clinical recommendations for health care providers treating pediatric patients with hidradenitis suppurativa with these biologic therapies?

Our data suggests that earlier diagnosis of hidradenitis suppurativa and initiation of adalimumab therapy may be associated with superior adalimumab survival in pediatric patients with hidradenitis suppurativa. However, further research is needed to investigate whether early management of hidradenitis suppurativa with biologics improves quality of life for patients by minimizing the morbidity and mortality associated with their disease.

AJMC: Considering these initial real-world findings, what are some next steps for research to build upon this data?

Future directions include comparing the drug survival of brand name TNF-α inhibitors (Humira and Remicade) and biosimilar drugs for adalimumab (ie, Amjevita, Cyltezo, Hyrimoz, Hadlima, Abrilada, Hulio, Yusimry, Idacio, Yuflyma, Simlandi) and infliximab (ie, Inflectra, Renflexis, Avsola) in both pediatric and adult patients with hidradenitis suppurativa. As novel biologic therapies (eg, interleukin [IL]-17, IL-12/IL-23, and Janus kinase inhibitors) begin to be used off label and are approved by the FDA for the treatment of pediatric and adult hidradenitis suppurativa, it will also be worth investigating how the drug survival of these biologics compares with the drug survival of TNF-α inhibitors.

Identifying differences in the drug survival and efficacy of biologic therapies in pediatric and adult patients with hidradenitis suppurativa will help physicians better tailor treatment recommendations for patients based on their age and disease severity.

References

1. Guo R, Jun M, Boiko S. Development of an educational module to raise awareness of and destigmatize HS among K-8 students. Presented at: Society for Pediatric Dermatology Annual Meeting; July 23-26, 2025; Seattle, Washington. POS-050.

2. Guo R, Jaleel T, Buros Stein A, Garza-Mayers AC, Kroshinsky D. Factors associated with drug survival of adalimumab and infliximab in pediatric patients with hidradenitis suppurativa. Presented at: Society for Pediatric Dermatology Annual Meeting; July 23-26, 2025; Seattle, Washington. POS-065.

3. Trotta MC, Alfano R, Cuomo G, et al. Comparison of timing to develop anti-drug antibodies to infliximab and adalimumab between adult and pediatric age groups, males and females. J Pediatr Pharmacol Ther. 2022;27(1):63-71. doi:10.5863/1551-6776-27.1.63