Hidradenitis Suppurativa: A Comprehensive Care Plan for Primary Care

Hidradenitis suppurativa (HS) is increasingly understood as a systemic inflammatory disease with effects that extend beyond the skin. Patients experience higher rates of metabolic syndrome, obesity, insulin resistance, and cardiovascular risk factors, as well as substantial psychiatric comorbidity, including depression, anxiety, and chronic pain. The multisystem effects of HS also include associations with inflammatory bowel disease and spondyloarthropathy.1-4

It is clear that effective management requires more than lesion-directed treatment. Routine screening for cardiometabolic risk and mental health conditions should be incorporated into clinical care, particularly in primary care settings where longitudinal follow-up is common. Addressing smoking cessation, weight management, sleep disturbance, and pain can improve quality of life and may enhance response to dermatologic therapies. A holistic, multidisciplinary approach supports better outcomes and reduces the long-term burden of disease for patients living with HS.1-4

Comprehensive HS care includes screening for and managing associated conditions1-4:

• Metabolic and cardiovascular risk: obesity, dyslipidemia, hypertension, insulin resistance/type 2 diabetes
• Mental health disorders: depression, anxiety, suicidality
• Inflammatory bowel disease and spondyloarthropathy (in symptomatic patients)
• Smoking, substance use, sleep disturbance, and chronic pain

PCP Note: Simple tools, eg the Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder-7 scale, validated pain scales, and routine cardiometabolic screening can be incorporated into primary care visits, with referral as needed.

Practical Primary-Care Tips & Pitfalls in Managing Hidradenitis Suppuritiva

DO:

• Ask about recurrent boils in axillae, groin, perineum, and under the breasts.

• Examine for tunnels and scarring, not just acute nodules.

• Use Hurley stage in your notes and referral letters.

• Address smoking, weight, and mental health proactively.

• Refer early to dermatology for Hurley II–III, rapid progression, or major QoL impact.

DON’T:

• Assume lesions are “just recurrent infections” without considering HS.

• Rely on repeated short antibiotic courses or I&D alone without a long-term plan.

• Forget to screen for comorbid metabolic and psychiatric conditions.

• Delay referral when HS is suspected but diagnosis is uncertain—early specialist input can prevent years of morbidity.

Quick Reference Checklist

✓ Recurrent painful nodules/abscesses in intertriginous areas?
✓ Chronicity (≥2 flares in 6 months) with scarring or tunnels?
✓ Typical locations (axillae, inguinal/perineal, inframammary, buttocks)?

→ Think HS

✓ Classify Hurley stage I–III.
✓ Initiate lifestyle measures, analgesia, topical ± oral antibiotics for mild disease.
✓ Screen for metabolic syndrome, depression/anxiety, IBD symptoms.
✓ Refer to dermatology for Hurley II–III, rapid progression, or significant impact.

For the other articles in this series on HS, please see:

Part 1 Hidradenitis Suppurativa: Recognition, Staging, and Management in Primary Care

Part 2 Hidradenitis Suppurativa Essentials for Primary Care: When to Suspect, Initial Therapy, and When to Refer

References

1. Sabat R, Alavi A, Wolk K, et al. Hidradenitis suppurativa. Lancet. 2025;405(10476):420-438. doi:10.1016/S0140-6736(24)02475-9

2. Ballard K, Shuman VL. Hidradenitis Suppurativa. In: StatPearls [Internet]. Updated May 6, 2024. Accessed December 15, 2025. https://www.ncbi.nlm.nih.gov/books/NBK534867/

3. Alikhan A, Sayed C, Alavi A, et al. North American clinical management guidelines for hidradenitis suppurativa: Part I. Diagnosis, evaluation, and the use of complementary and procedural management. J Am Acad Dermatol. 2019;81(1):76-90. doi:10.1016/j.jaad.2019.02.067

4. Kaya G, Ozgen FP, Kelahmedoglu O, et al. Demographic features, clinical characteristics, and comorbidities in hidradenitis suppurativa. Front Med. 2025;12:1499509. doi:10.3389/fmed.2024.1499509