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

Effective management of hidradenitis suppurativa (HS) depends on early recognition, appropriate staging, and timely escalation of therapy. Because HS often presents initially in primary care, frontline clinicians play a pivotal role in identifying characteristic patterns, eg, recurrent painful nodules or abscesses in intertriginous areas, partial responses to antibiotics, and progressive scarring or tunnel formation, and distinguishing the disease from simple infection or folliculitis.

Delays in diagnosis, which commonly extend for several years, are associated with increased disease severity, cumulative tissue damage, and reduced quality of life.

Initial management in primary care focuses on patient education, risk-factor modification, symptom control, and treatment of mild disease. Topical therapies, intralesional corticosteroids, and oral tetracyclines may provide benefit in early or limited HS, while counseling on smoking cessation, weight management, friction reduction, and pain control is essential at all stages. However, HS is a chronic inflammatory condition, and many patients will require referral for more advanced care.

For patients with moderate to severe disease, rapid progression, or substantial physical or psychosocial burden, dermatology-led management is indicated. Systemic antibiotics, hormonal therapies, and biologic agents targeting key inflammatory pathways, most notably TNF-α and IL-17, now form the backbone of evidence-based treatment for advanced HS. Understanding when to initiate, continue, or escalate therapy enables clinicians to coordinate care effectively and improve long-term outcomes for patients living with this debilitating disease.

Consider HS when you see1-3:

• Recurrent painful nodules or abscesses in intertriginous sites
• Nonhealing “boils” that leave scars, tunnels, or double-headed comedones
• Symptoms persisting >6 months despite standard infection management

Refer to dermatology when1-4:

• Hurley stage II or III disease is present
• Pain, drainage, or psychosocial impact is substantial
• There is diagnostic uncertainty (eg, possible Crohn disease, atypical locations)
• Systemic therapy (prolonged antibiotics, biologics) or procedural interventions are being considered

PCP Note: Early referral is particularly important in younger patients with rapidly progressive disease, extensive tunnels, or significant impact on function or quality of life.

Initial Management in Primary Care

Primary care clinicians often provide the first line of management and ongoing comorbidity care.

Lifestyle and General Measures1

• Smoking cessation: strongly recommended; may reduce disease activity and is essential for overall health.
• Weight management: counsel on weight loss where appropriate; even modest loss can reduce friction, maceration, and possibly flare frequency.
• Friction and moisture control: loose clothing, avoidance of shaving in affected areas, gentle cleansers; consider antiseptic washes (chlorhexidine, benzoyl peroxide) in mild disease.
• Pain management: NSAIDs, acetaminophen; consider neuropathic pain agents or referral to pain management in chronic severe pain.

Topical and Oral Therapies for Mild Disease

For Hurley I or limited Hurley II disease, practical guidelines and North American/European recommendations suggest1-3,7,8 :

• Topical clindamycin 1% (solution or gel) for localized lesions
• Intralesional corticosteroids (eg, triamcinolone) for individual inflamed nodules when available and appropriate
• Oral tetracyclines (eg, doxycycline, minocycline) for several months for anti-inflammatory benefit in mild to moderate disease

PCP Note: Acute abscesses may require incision and drainage (I&D), but this should be accompanied by ongoing medical management; I&D alone does not alter disease course.

Systemic Therapy and Biologics (Dermatology-led)

For moderate to severe HS (Hurley II–III), evidence-based guidelines support escalation to systemic therapies, typically under dermatology supervision1,2,5,8:

• Prolonged systemic antibiotics (eg, tetracyclines; combination clindamycin + rifampin)
• Hormonal therapy in appropriate patients (eg, combined oral contraceptives, anti-androgens)

Biologic agents

• Adalimumab (anti–TNF-α): first FDA-approved treatment for moderate-to-severe HS (2015) with established efficacy in reducing abscesses and tunnels.9
• Secukinumab (IL-17A inhibitor): FDA-approved for adults with moderate-to-severe HS (2023).10
• Bimekizumab (IL-17A/IL-17F inhibitor): FDA-approved for adults with moderate-to-severe HS (2024).11

PCP Note: Dermatology will select and monitor systemic agents, but primary care plays a key role in screening for infections and comorbidities, vaccination updates, and shared decision-making.

Next: Comorbidity Screening and Holistic Care in Hidradenitis Suppurativa

References

1. 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

2. Zouboulis CC, Szepietowski JC, Alavi A, et al. European S2k guidelines for hidradenitis suppurativa/acne inversa: Part 2—Treatment. J Eur Acad Dermatol Venereol. 2025;39(5):899-941. doi:10.1111/jdv.20472

3. Rivera-Díaz J, Rocafort SL, Bonilla IM, Moreda AJ, Cartagena JR. A comprehensive review of hidradenitis suppurativa: from pathogenesis to clinical insights and novel therapeutics. Int J Med Students. 2023;11(3). doi.org/10.5195/ijms.2023.2809

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

5. 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

6. 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/

7. Johnston LA, Alhusayen R, Bourcier M, et al. Practical guidelines for managing patients with hidradenitis suppurativa: An update. J Cutan Med Surg. 2022;26(S2):2S-24S. doi:10.1177/12034754221116115

8. Garg A, Hsia J, Porter ML, Shi V.Current treatments and future directions for hidradenitis suppurativa. Dermatol Ther (Heidelb). 2025;15(9):2361-2377. doi: 10.1007/s13555-025-01487-y

9. Humira. Prescribing information. AbbVie; July 2025. Accessed December 15, 2025. https://www.rxabbvie.com/pdf/humira.pdf

10. Cosentyx . Prescribing Information. Novartis; August 2025. Accessed December 15, 2025. https://www.novartis.com/us-en/sites/novartis_us/files/cosentyx.pdf

11. Bimzelx. Prescribing information. UCB USA; November 2024. Accessed December 15, 2025.