Jim Treat, MD and Jennie Hsiao, MD discuss highlights from their lecture on Surgical Vs. Medical Management in Dermatology on Saturday, November 11, 2023, at the 4th Annual Elevate-Derm PA/NP Dermatology Conference in Coachella Valley, CA.

In this video

In this interview with dermatology PA Lisa Weiss, Dr. Hsiao frames HS as a disease that usually calls for combination therapy — most patients benefit from both surgical and medical approaches. She reserves procedures for lesions that are "more fixed," the persistently problematic areas that don't respond to medical management, and stresses setting expectations: tunnels and sinus tracts "are not going to melt away" with current medical treatments, so de-roofing, wide local excision, or referral to plastic surgery may be needed. Her key pearl is to maintain medical management throughout surgery, since patients tend to flare in new areas — Dr. Treat adds that medical therapy handles prevention while surgery targets the most active, recalcitrant sites.

Dr. Treat cautions against being too eager to label a 12- or 13-year-old with a couple of nodules or pustules as HS, and suggests a culture early on when the presentation is unusual — occasionally these patients actually have Staph, and a culture reassures parents too. Dr. Hsiao closes on an optimistic note, calling this an exciting time for a disease that has "devastated so many lives for so long," pointing to a second FDA approval in HS and the difference providers make by building rapport and framing care as a shared treatment journey.

  • Think combination therapy in HS — most patients need more than one type of treatment to optimize outcomes.
  • Reserve surgery for fixed, persistent, recalcitrant lesions; tunnels and sinus tracts won't resolve with medical therapy alone.
  • Maintain medical management during surgical procedures, since patients tend to flare in new areas.
  • In kids with only one or two spots or an unusual presentation, consider a culture early to confirm it's truly HS and not Staph — and look for double comedones and other clinical signs.
  • Set expectations from the start: HS is a treatment journey, and building rapport makes a real difference.