A Comprehensive Review of Hidradenitis Suppurativa: From Pathogenesis to Clinical Insights & Novel Therapeutic Advancements
DOI:
https://doi.org/10.5195/ijms.2025.2809Keywords:
Hidradenitis Suppurativa, Inflammation, Intertriginous Areas, Follicular Oclussion, Acne InversaAbstract
Hidradenitis suppurativa (HS) is a chronic, recurrent, and inflammatory follicular skin disease that profoundly impairs patients’ quality of life. Pathogenesis is thought to begin with follicular occlusion, leading to painful nodules, abscesses, and sinus tract formation. Pain is a central and debilitating symptom, occurring as both acute flare-ups and persistent chronic discomfort, significantly contributing to morbidity and psychological distress. This narrative review was conducted with methodological rigor, employing the Scale for the Assessment of Narrative Review Articles (SANRA) to ensure a thorough literature search and critical appraisal of evidence. Clinical diagnosis relies on the presence of characteristic lesions, typical involvement of intertriginous areas, and recurrence at least twice within six months. A major challenge remains the diagnostic delay, averaging 6 to 10 years from symptom onset, which is linked to increased disease severity, higher healthcare costs, and loss of productivity. Disease severity is commonly evaluated using tools such as the Hurley staging system, Sartorius scoring, and the HS Physician Global Assessment. Therapeutic options include antibiotics (e.g., clindamycin, rifampin), retinoids (e.g., acitretin, isotretinoin), hormonal agents (e.g., spironolactone, oral contraceptives), intralesional corticosteroids, botulinum toxin injections, laser hair removal, and photodynamic therapy. Biologic therapies, such as adalimumab and infliximab, represent emerging treatment modalities. Under-recognition and limited diagnostic tools continue to impede timely intervention. This review aims to improve awareness of HS, highlight its varied clinical presentations, and summarize evolving management strategies for the medical community.
References
1. Chen W, Plewig G. Should hidradenitis suppurativa/acne inversa best be renamed as “dissecting terminal hair folliculitis”? Exp Dermatol. 2017 Jun;26(6):544–7.
2. Kimball AB, Kirby J, Ingram JR, Tran T, Pansar I, Ciaravino V, et al. Burden of Hidradenitis Suppurativa: A Systematic Literature Review of Patient Reported Outcomes. Dermatol Ther. 2024 Jan;14(1):83–98.
3. Shavit E, Alavi A, Bechara FG, Bennett RG, Bourcier M, Cibotti R, et al. Proceeding report of the Second Symposium on Hidradenitis Suppurativa Advances ( SHSA ) 2017. Exp Dermatol. 2019 Jan;28(1):94–103.
4. Garg A, Kirby JS, Lavian J, Lin G, Strunk A. Sex- and Age-Adjusted Population Analysis of Prevalence Estimates for Hidradenitis Suppurativa in the United States. JAMA Dermatol. 2017 Aug 1;153(8):760.
5. Zouboulis CC, Nogueira Da Costa A, Fimmel S, Zouboulis KC. Apocrine glands are bystanders in hidradenitis suppurativa and their involvement is gender specific. J Eur Acad Dermatol Venereol. 2020 Jul;34(7):1555–63.
6. Prens E, Deckers I. Pathophysiology of hidradenitis suppurativa: An update. J Am Acad Dermatol. 2015 Nov;73(5):S8–11.
7. Johnston LA, Alhusayen R, Bourcier M, Delorme I, George R, O’Brien E, et al. Practical Guidelines for Managing Patients With Hidradenitis Suppurativa: An Update. J Cutan Med Surg. 2022 Sep;26(2_suppl):2S-24S.
8. Zouboulis CC, Benhadou F, Byrd AS, Chandran NS, Giamarellos‐Bourboulis EJ, Fabbrocini G, et al. What causes hidradenitis suppurativa ?—15 years after. Exp Dermatol. 2020 Dec;29(12):1154–70.
9. Ingram JR, Jenkins-Jones S, Knipe DW, Morgan CLI, Cannings-John R, Piguet V. Population-based Clinical Practice Research Datalink study using algorithm modelling to identify the true burden of hidradenitis suppurativa. Br J Dermatol. 2018 Apr 1;178(4):917–24.
10. Jfri A, Netchiporouk E, Raymond K, Litvinov IV, O’Brien E. Association of clinical severity scores with psychosocial impact in patients with hidradenitis suppurativa. J Am Acad Dermatol. 2021 Jun;84(6):1712–5.
11. Fimmel S, Zouboulis CC. Comorbidities of hidradenitis suppurativa (acne inversa). Dermatoendocrinol. 2010 Jan;2(1):9–16.
12. Nikolakis G, Kaleta KP, Vaiopoulos AG, Wolter K, Baroud S, Wojas-Pelc A, et al. Phenotypes and Pathophysiology of Syndromic Hidradenitis Suppurativa: Different Faces of the Same Disease? A Systematic Review. Dermatology. 2021;237(5):673–97.
13. Garg A, Neuren E, Cha D, Kirby JS, Ingram JR, Jemec GBE, et al. Evaluating patients’ unmet needs in hidradenitis suppurativa: Results from the Global Survey Of Impact and Healthcare Needs (VOICE) Project. J Am Acad Dermatol. 2020 Feb;82(2):366–76.
14. Baethge C, Goldbeck-Wood S, Mertens S. SANRA—a scale for the quality assessment of narrative review articles. Res Integr Peer Rev. 2019 Dec;4(1):5.
15. Nguyen TV, Damiani G, Orenstein LAV, Hamzavi I, Jemec GB. Hidradenitis suppurativa: an update on epidemiology, phenotypes, diagnosis, pathogenesis, comorbidities and quality of life. J Eur Acad Dermatol Venereol. 2021 Jan;35(1):50–61.
16. Alotaibi HM. Incidence, Risk Factors, and Prognosis of Hidradenitis Suppurativa Across the Globe: Insights from the Literature. Clin Cosmet Investig Dermatol. 2023 Mar;Volume 16:545–52.
17. Bukvić Mokos Z, Miše J, Balić A, Marinović B. Understanding the Relationship Between Smoking and Hidradenitis Suppurativa. Acta Dermatovenerol Croat ADC. 2020 Jul;28(1):9–13.
18. Cartron A, Driscoll MS. Comorbidities of hidradenitis suppurativa: A review of the literature. Int J Womens Dermatol. 2019 Dec;5(5):330–4.
19. Jenkins T, Isaac J, Edwards A, Okoye GA. Hidradenitis Suppurativa. Dermatol Clin. 2023 Jul;41(3):471–9.
20. Snyder CL, Chen SX, Porter ML. Obstacles to Early Diagnosis and Treatment of Hidradenitis Suppurativa: Current Perspectives on Improving Clinical Management. Clin Cosmet Investig Dermatol. 2023 Jul;Volume 16:1833–41.
21. Garg A, Neuren E, Strunk A. Hidradenitis Suppurativa Is Associated with Polycystic Ovary Syndrome: A Population-Based Analysis in the United States. J Invest Dermatol. 2018 Jun;138(6):1288–92.
22. Egeberg A, Gislason GunnarH, Hansen PR. Risk of Major Adverse Cardiovascular Events and All-Cause Mortality in Patients With Hidradenitis Suppurativa. JAMA Dermatol. 2016 Apr 1;152(4):429.
23. Scala E, Cacciapuoti S, Garzorz-Stark N, Megna M, Marasca C, Seiringer P, et al. Hidradenitis Suppurativa: Where We Are and Where We Are Going. Cells. 2021 Aug 15;10(8):2094.
24. Acharya P, Mathur M. Hidradenitis suppurativa and smoking: A systematic review and meta-analysis. J Am Acad Dermatol. 2020 Apr;82(4):1006–11.
25. Kurzen H, Kurzen M. Secondary prevention of hidradenitis suppurativa. Dermatol Rep [Internet]. 2019 Oct 25 [cited 2024 Jul 24];11(2). Available from: https://www.pagepress.org/journals/index.php/dr/article/view/8243
26. Gold DA, Reeder VJ, Mahan MG, Hamzavi IH. The prevalence of metabolic syndrome in patients with hidradenitis suppurativa. J Am Acad Dermatol. 2014 Apr;70(4):699–703.
27. Thomas CL, Gordon KD, Mortimer PS. Rapid resolution of hidradenitis suppurativa after bariatric surgical intervention. Clin Exp Dermatol. 2014 Apr;39(3):315–8.
28. Mintoff D, Benhadou F, Pace NP, Frew JW. Metabolic syndrome and hidradenitis suppurativa: epidemiological, molecular, and therapeutic aspects. Int J Dermatol. 2022 Oct;61(10):1175–86.
29. Hoffman L, Ghias M, Lowes M. Pathophysiology of hidradenitis suppurativa. Semin Cutan Med Surg. 2017 Jun;36(2):47–54.
30. Ingram JR. Hidradenitis suppurativa: Pathogenesis, clinical features, and diagnosis [Internet]. UpToDate. 2023 [cited 2024 Jun 17]. Available from: https://www.uptodate.com/contents/hidradenitis-suppurativa-pathogenesis-clinical-features-and-diagnosis?search=pathophysiology+of+hidradenitis+supurativa&source=search_result&selectedTitle=1~66&usage_type=default&display_rank=1
31. Goldburg SR, Strober BE, Payette MJ. Hidradenitis suppurativa: Epidemiology, clinical presentation, and pathogenesis. J Am Acad Dermatol. 2020 May;82(5):1045–58.
32. Chen R, Guo R, Petty AJ, Jaleel T. Immune Dysregulation and Current Targeted Biologics in Hidradenitis Suppurativa. Immuno. 2024 Feb 2;4(1):57–76.
33. Kozera EK, Lowes MA, Hsiao JL, Frew JW. Clinical considerations in the management of hidradenitis suppurativa in women. Int J Womens Dermatol. 2021 Dec;7(5):664–71.
34. 35. Diaz MJ, Aflatooni S, Abdi P, Li R, Anthony MR, Neelam S, et al. Hidradenitis Suppurativa: Molecular Etiology, Pathophysiology, and Management—A Systematic Review. Curr Issues Mol Biol. 2023 May 17;45(5):4400–15.
35. Chu CB, Yang CC, Tsai SJ. Hidradenitis Suppurativa: Disease Pathophysiology and Sex Hormones. Chin J Physiol. 2021;64(6):257–65.
36. Garg A, Naik HB, Kirby JS. A Practical Guide for Primary Care Providers on Timely Diagnosis and Comprehensive Care Strategies for Hidradenitis Suppurativa. Am J Med. 2023 Jan;136(1):42–53.
37. Kokolakis G, Wolk K, Schneider-Burrus S, Kalus S, Barbus S, Gomis-Kleindienst S, et al. Delayed Diagnosis of Hidradenitis Suppurativa and Its Effect on Patients and Healthcare System. Dermatology. 2020;236(5):421–30.
38. Shelby D. Hidradenitis Suppurativa: A Disease Under-Diagnosed and Under Treated. [Internet]. 2018 [cited 2024 Jun 18]. Available from: https://www.skinbonescme.com/2018/02/01/hidradenitis-suppurativa-disease-underdiagnosed-undertreated/
39. Kirby J, Kim K, Zivkovic M, Wang S, Garg V, Danavar A, et al. Uncovering the burden of hidradenitis suppurativa misdiagnosis and underdiagnosis: a machine learning approach. Front Med Technol. 2024 Mar 25;6:1200400.
40. Preda‐Naumescu A, Ahmed HN, Mayo TT, Yusuf N. Hidradenitis suppurativa: pathogenesis, clinical presentation, epidemiology, and comorbid associations. Int J Dermatol [Internet]. 2021 Nov [cited 2024 Jul 24];60(11). Available from: https://onlinelibrary.wiley.com/doi/10.1111/ijd.15579
41. Okun MM, Flamm A, Werley EB, Kirby JS. Hidradenitis Suppurativa: Diagnosis and Management in the Emergency Department. J Emerg Med. 2022 Nov;63(5):636–44.
42. Díaz D, Rivera A, Otero V, Rueda L. Epidemiology of Hidradenitis Suppurativa: Current Status. Curr Dermatol Rep. 2022 Oct 11;11(4):336–40.
43. Saunte DML, Jemec GBE. Hidradenitis Suppurativa: Advances in Diagnosis and Treatment. JAMA. 2017 Nov 28;318(20):2019.
44. Ghanian S, Yamanaka-Takaichi M, Naik HB, Alavi A. Medical Management of Hidradenitis Suppurativa with Non-Biologic Therapy: What’s New? Am J Clin Dermatol. 2022 Mar;23(2):167–76.
45. Alikhan A, Sayed C, Alavi A, Alhusayen R, Brassard A, Burkhart C, et al. North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations. J Am Acad Dermatol. 2019 Jul;81(1):91–101.
46. Singh S, Desai K, Gillern S. Management of Pilonidal Disease and Hidradenitis Suppurativa. Surg Clin North Am. 2024 Jun;104(3):503–15.
47. Gerriets V, Goyal A, Khaddour K. Tumor Necrosis Factor Inhibitors. [Internet]. StatPearls. 2023 [cited 2024 Jun 27]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482425/
48. U.S. Food and Drug Administration. COSENTYX® (secukinumab) injection, for subcutaneous or intravenous use [Internet]. 2023 [cited 2024 Jun 10]. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/125504s066,761349s004lbl.pdf
49. U.S. Food and Drug Administration. BIMZELX® (bimekizumab-bkzx) injection, for subcutaneous use [Internet]. 2023 [cited 2024 Jun 10]. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/761151s000lbl.pdf
50. U.S. Food and Drug Administration. TALTZ (ixekizumab) injection, for subcutaneous use [Internet]. 2022 [cited 2024 Jun 10]. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/125521s024lbl.pdf
51. U.S. Food and Drug Administration. SILIQTM (brodalumab) injection, for subcutaneous use [Internet]. 2017 [cited 2024 Jun 10]. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/761032lbl.pdf
52. 53. U.S. Food and Drug Administration. ILUMYATM (tildrakizumab-asmn) injection, for subcutaneous use [Internet]. 2018 [cited 2024 Jun 10]. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/761067s000lbl.pdf
53. U.S. Food and Drug Administration. SKYRIZI® (risankizumab-rzaa) injection, for subcutaneous use [Internet]. 2022 [cited 2024 Jun 10]. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/761105s014lbl.pdf
54. U.S. Food and Drug Administration. TREMFYA® (guselkumab) injection, for subcutaneous use [Internet]. 2020 [cited 2024 Jun 11]. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/761061s009lbl.pdf
55. U.S. Food and Drug Administration. STELARA® (ustekinumab) injection, for subcutaneous or intravenous [Internet]. 2016 [cited 2024 Jun 11]. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/761044lbl.pdf
56. U.S. Food and Drug Administration. KINERET® (anakinra) injection, for subcutaneous use [Internet]. 2020 [cited 2024 Jun 11]. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/103950s5189lbl.pdf
57. U.S. Food and Drug Administration. DUPIXENT® (dupilumab) injection, for subcutaneous use [Internet]. 2022 [cited 2024 Jun 11]. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/761055s042lbl.pdf
58. U.S. Food and Drug Administration. ILARIS® (canakinumab) for injection, for subcutaneous use [Internet]. 2016 [cited 2024 Jun 11]. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/BLA125319_858687lbl.pdf
59. Molinelli E, Gioacchini H, Sapigni C, Diotallevi F, Brisigotti V, Rizzetto G, et al. New Insight into the Molecular Pathomechanism and Immunomodulatory Treatments of Hidradenitis Suppurativa. Int J Mol Sci. 2023 May 8;24(9):8428.
60. Mital R, Gray A, Minta A, Almhana F, Amin S, Hydol-Smith J, et al. Novel and Off-Label Biologic Use in the Management of Hidradenitis Suppurativa, Pyoderma Gangrenosum, Lichen Planus, and Seborrheic Dermatitis: A Narrative Review. Dermatol Ther. 2023 Jan;13(1):77–94.
61. Ruggiero A, Picone V, Martora F, Fabbrocini G, Megna M. Guselkumab, Risankizumab, and Tildrakizumab in the Management of Psoriasis: A Review of the Real-World Evidence. Clin Cosmet Investig Dermatol. 2022 Aug;Volume 15:1649–58.
62. Macca L, Li Pomi F, Ingrasciotta Y, Morrone P, Trifirò G, Guarneri C. Hidradenitis suppurativa and psoriasis: the odd couple. Front Med. 2023 Jul 7;10:1208817.
63. Molinelli E, Gioacchini H, Marani A, Rizzetto G, Gambini D, De Simoni E, et al. Topical and Systemic Retinoids in the Management of Hidradenitis Suppurativa: A Comprehensive Literature Review. Dermatol Ther. 2024 May;14(5):1079–91.
64. Shih T, Lee K, Seivright JR, De DR, Shi VY, Hsiao JL. Hyperhidrosis treatments in hidradenitis suppurativa: A systematic review. Dermatol Ther [Internet]. 2022 Jan [cited 2024 Jul 24];35(1). Available from: https://onlinelibrary.wiley.com/doi/10.1111/dth.15210
65. Alster TS, Harrison IS. Alternative Clinical Indications of Botulinum Toxin. Am J Clin Dermatol. 2020 Dec;21(6):855–80.
Downloads
Published
How to Cite
License
Copyright (c) 2025 Jeevan Rivera-Díaz, Sofía Laguna Rocafort, Ingrid M. Bonilla Mercado, Alejandra Figueroa Moreda, Jose Rabelo Cartagena
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors who publish with this journal agree to the following terms:
- The Author retains copyright in the Work, where the term “Work” shall include all digital objects that may result in subsequent electronic publication or distribution.
- Upon acceptance of the Work, the author shall grant to the Publisher the right of first publication of the Work.
- The Author shall grant to the Publisher and its agents the nonexclusive perpetual right and license to publish, archive, and make accessible the Work in whole or in part in all forms of media now or hereafter known under a Creative Commons Attribution 4.0 International License or its equivalent, which, for the avoidance of doubt, allows others to copy, distribute, and transmit the Work under the following conditions:
- Attribution—other users must attribute the Work in the manner specified by the author as indicated on the journal Web site; with the understanding that the above condition can be waived with permission from the Author and that where the Work or any of its elements is in the public domain under applicable law, that status is in no way affected by the license.
- The Author is able to enter into separate, additional contractual arrangements for the nonexclusive distribution of the journal's published version of the Work (e.g., post it to an institutional repository or publish it in a book), as long as there is provided in the document an acknowledgment of its initial publication in this journal.
- Authors are permitted and encouraged to post online a prepublication manuscript (but not the Publisher’s final formatted PDF version of the Work) in institutional repositories or on their Websites prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work. Any such posting made before acceptance and publication of the Work shall be updated upon publication to include a reference to the Publisher-assigned DOI (Digital Object Identifier) and a link to the online abstract for the final published Work in the Journal.
- Upon Publisher’s request, the Author agrees to furnish promptly to Publisher, at the Author’s own expense, written evidence of the permissions, licenses, and consents for use of third-party material included within the Work, except as determined by Publisher to be covered by the principles of Fair Use.
- The Author represents and warrants that:
- the Work is the Author’s original work;
- the Author has not transferred, and will not transfer, exclusive rights in the Work to any third party;
- the Work is not pending review or under consideration by another publisher;
- the Work has not previously been published;
- the Work contains no misrepresentation or infringement of the Work or property of other authors or third parties; and
- the Work contains no libel, invasion of privacy, or other unlawful matter.
- The Author agrees to indemnify and hold Publisher harmless from the Author’s breach of the representations and warranties contained in Paragraph 6 above, as well as any claim or proceeding relating to Publisher’s use and publication of any content contained in the Work, including third-party content.
Enforcement of copyright
The IJMS takes the protection of copyright very seriously.
If the IJMS discovers that you have used its copyright materials in contravention of the license above, the IJMS may bring legal proceedings against you seeking reparation and an injunction to stop you using those materials. You could also be ordered to pay legal costs.
If you become aware of any use of the IJMS' copyright materials that contravenes or may contravene the license above, please report this by email to contact@ijms.org
Infringing material
If you become aware of any material on the website that you believe infringes your or any other person's copyright, please report this by email to contact@ijms.org
