Hidradenitis suppurativa (HS)

What changes during this transition

Hidradenitis suppurativa is among the most underdiagnosed and most stigmatized chronic conditions in dermatology. Average diagnostic delay from first symptom to correct diagnosis runs 7-10 years across published cohorts. Patients spend that decade being told they have 'recurrent boils,' 'bad acne,' 'hygiene problems,' or 'staph infections' by clinicians who were never trained to recognize the disease pattern. The anatomy compounds the shame — axillae, groin, perianal, and inframammary regions are where lesions appear, so patients delay seeking care, hide the disease from partners, and arrive at dermatology already carrying the cumulative weight of being dismissed. Mental health screening is part of standard HS care for a reason: depression rates are materially elevated, and suicide risk is high enough that the HS Foundation and patient organizations like Hope for HS treat suicide-ideation screening as a core competency, not an afterthought. Editorial sensitivity in writing about HS is not decoration — it's load-bearing. The disease itself is a chronic autoinflammatory follicular occlusion disorder. Hair follicle occlusion ruptures into the surrounding dermis, triggering a cascade of TNF, IL-17A/F, IL-1 family cytokines, and complement activation. Sinus tracts form as the disease becomes chronic; scarring is the archaeological record of inflammation that was never controlled. Hurley staging captures severity: Stage I is recurrent abscesses without tracts or scarring; Stage II is recurrent abscesses with tract formation and limited scarring; Stage III is diffuse involvement with multiple interconnected tracts and extensive scarring. Female predominance runs about 3:1. African-American and African-ancestry populations carry higher prevalence. Onset is postpubertal. Genetic forms (gamma-secretase complex mutations: NCSTN, PSEN1, PSENEN) account for a minority of familial cases. The comorbidity load is unusually heavy and clinically relevant. Obesity and metabolic syndrome are highly prevalent; type 2 diabetes risk is elevated; cardiovascular risk is elevated independent of metabolic comorbidity; IBD overlap is roughly 25% (Crohn's particularly); spondyloarthropathy, acne conglobata, PCOS, and follicular occlusion tetrad conditions cluster together; depression and anxiety run materially above population baseline. Pregnancy management has a specific note: certolizumab pegol is the preferred TNF inhibitor in pregnancy because its Fc-free structure minimizes placental transfer. Lifestyle medicine carries the #1 non-pharmacologic intervention in HS, and it's smoking cessation. Smokers carry roughly 4x HS risk and cessation improves disease course — this is among the strongest non-pharmacologic data in the field. Weight management improves both HS and the constellation of metabolic comorbidities. None of this is peptide territory; all of it is dominant over any supplement question. Pharmacotherapy has been reshaped three times in nine years. Adalimumab (Humira) was FDA-approved September 2015 as the first biologic for HS based on PIONEER I and PIONEER II Phase 3 trials. Secukinumab (Cosentyx, anti-IL-17A) was FDA-approved October 2023 via SUNSHINE and SUNRISE Phase 3 — adding a second mechanism. Bimekizumab (Bimzelx, dual anti-IL-17A/F) was FDA-approved July 2024 via BE HEARD I and II Phase 3 — adding a third. Povorcitinib (INCB054707, JAK1 inhibitor) is in Phase 3 STOP-HS with 2025 readout; sonelokimab (anti-IL-17A/F nanobody) is in Phase 3 VELA; avacopan (C5aR1) is in Phase 2/3 ASTRA. Off-label biologics including infliximab and ustekinumab are used in specialist hands. IL-1 family inhibitors (anakinra, canakinumab) have signals in select cases. Procedural care matters at moderate-to-severe disease. Intralesional steroid injections for individual painful lesions. Incision and drainage for acute abscesses (though many HS specialists prefer deroofing). Deroofing technique opens chronic tracts without wide excision and has become the procedural workhorse. CO2 laser deroofing extends the technique. Wide surgical excision remains appropriate for established Hurley III disease in select anatomic regions. Mental health screening is part of standard HS care. PHQ-9 administration with active suicide-ideation questions belongs in standard HS clinic visits. Peptides do not fit this disease. BPC-157 fails on autoinflammatory follicular biology and on the IBD-overlap framing that doesn't propagate mechanically. TB-500 fails on altitude — scarring is downstream of unmanaged inflammation. Thymosin alpha-1 is mechanistically backwards in an autoinflammatory disease driven by TNF/IL-17/IL-1 overactivation. LL-37 is directly contraindicated because endogenous cathelicidin is already upregulated in HS lesional skin and is part of the pathologic cascade. NMN has no HS data and adds polypharmacy load.