New hidradenitis suppurativa guideline puts biologics at center of care

Clinical takeaway: For patients with moderate-to-severe hidradenitis suppurativa (HS), biologic therapy now has the strongest support, with adalimumab, bimekizumab, infliximab, and secukinumab all receiving strong recommendations. The guideline also emphasizes routine pain assessment, multidisciplinary management, and minimizing treatment delays caused by step-therapy requirements.

The American Academy of Dermatology (AAD) and Hidradenitis Suppurativa Foundation (HSF) have released their first joint guideline for the management of HS, providing 37 evidence-based recommendations spanning medical, procedural, surgical, supportive, and lifestyle interventions. The guideline applies to adults, adolescents, and children aged 9 years and older.

Among drug therapies, the strongest recommendations are reserved for biologics in moderate-to-severe disease. Adalimumab, bimekizumab, infliximab, and secukinumab are all recommended based on evidence showing clinically meaningful reductions in inflammatory lesions and improvements in quality of life. The panel also conditionally recommends continuing adalimumab during the perioperative period for patients undergoing HS surgery.

Several nonbiologic therapies received conditional recommendations. These include topical clindamycin, resorcinol, and ruxolitinib; oral doxycycline and tetracycline; combination clindamycin plus rifampin; IV ertapenem for refractory moderate-to-severe disease; spironolactone; short-term systemic corticosteroids; and the JAK inhibitor upadacitinib.

The guideline also identifies treatments that should generally be avoided. Conditional recommendations were made against acitretin, isotretinoin, methotrexate, azathioprine, avacopan, etanercept, guselkumab, risankizumab, and vilobelimab because current evidence does not support routine use for HS. Pediatric and adolescent patients should not receive radiotherapy for HS management.

For patients with tunnels, abscesses, or recurrent lesions, the workgroup supports a range of procedural options, including deroofing, incision and drainage, local or regional excision, laser hair removal, botulinum toxin, and intralesional triamcinolone. The authors emphasize that effective HS care often requires combining medical and procedural approaches.

Notably, pain management receives dedicated attention. The guideline recommends routine pain assessment at every visit and supports tailored management strategies ranging from topical analgesics and NSAIDs to neuropathic pain agents and, when necessary, short-term opioid use. Tobacco cessation is also conditionally recommended because smoking may impair treatment response.

The panel found insufficient evidence to recommend GLP-1–based therapies, weight-loss interventions, specific dietary approaches, oral contraceptives, finasteride, or several emerging HS treatments, highlighting the need for additional research.

The guideline also takes an unusually strong stance against insurer-mandated step therapy, stating that available evidence shows treatment delays and reduced access to guideline-concordant care without demonstrated clinical benefit.

“These guidelines establish an evidence-based standard of care for HS, giving patients, dermatologists, and payers a shared roadmap for what high-quality HS care looks like,” said guideline co-chair Haley B. Naik, MD, president of the Hidradenitis Suppurativa Foundation. “Every person living with HS deserves care that meets this standard.”

Key recommendations

• Strongly recommend adalimumab, bimekizumab, infliximab, and secukinumab for moderate-to-severe HS.
• Conditionally recommend topical clindamycin, resorcinol, and ruxolitinib.
• Conditionally recommend doxycycline, tetracycline, clindamycin plus rifampin, and ertapenem.
• Conditionally recommend spironolactone, short-term systemic corticosteroids, and upadacitinib.
• Continue adalimumab during HS surgery when appropriate.
• Routinely assess pain and incorporate supportive pain-management strategies.
• Encourage tobacco cessation.
• Consider zinc supplementation and vitamin D repletion when indicated.
• Recommend against acitretin, isotretinoin, methotrexate, azathioprine, avacopan, etanercept, guselkumab, risankizumab, and vilobelimab.
• Recommend against radiotherapy in pediatric and adolescent patients.

Source: Naik HB, et al. (2026 Oct 20) J Am Acad Dermatol. Joint American Academy of Dermatology-Hidradenitis Suppurativa Foundation guidelines of care for the management of hidradenitis suppurativa