Closing the Diagnosis Gap
Recorded at the Elevate-Derm Fall conference in Tampa, this panel with Dr. Robert Micheletti tackles a persistent problem in hidradenitis suppurativa: patients waiting an average of seven to ten years for a diagnosis. Micheletti notes awareness is improving, but too many cases are still missed on that first encounter.
He offers a simple, validated screening question that gives roughly a 95% likelihood of an HS diagnosis: has the patient had two or more episodes of an inflammatory nodule or papule in the body fold area within the last six months? Micheletti says this was validated in a European epidemiology study, and while a dermatology audience is generally good at recognizing HS, it helps to put the diagnosis into words for colleagues who aren't as familiar with the disease.
Why Early Diagnosis Changes the Trajectory
Micheletti frames early diagnosis as something that can change the trajectory of a patient's whole life. He points to the quality-of-life impact of HS as worse than just about any other condition seen in dermatology, affecting work, relationships, and more. Untreated mild stage one disease can progress, and scarring and tract formation happen when the disease isn't being addressed.
This is where he introduces the concept of a 'window of opportunity' — being more aggressive earlier to spare patients from developing the more difficult phenotypes that, as he puts it, clinicians don't have good tools to address right now.
The First Conversation: Empathy Before Everything
Micheletti stresses that the first visit is largely about giving patients space to talk with someone who actually understands the disease. Many have been bounced around and told to lose weight, quit smoking, or fix their 'hygiene.' While weight and smoking may have some relevance, he is emphatic that this is not the patient's fault, and that empathy is what earns the trust needed for long-term success.
The main take-home message he wants patients to leave with is that he's going to help them. If a patient arrives as a relative blank slate, almost anything the team does is going to help. He describes it as a process, iterative over time, done together on the same team — and above all, a message of hope, which the hosts agree is essential for this condition.
From Historic Therapies to Biologics
For mild to moderate stage one disease — and from an insurance-approval standpoint — Micheletti typically starts with doxycycline, and spironolactone for female patients. He also uses washes like chlorhexidine, topical clindamycin, and compounded 15% resorcinol cream for flares. He notes preliminary interest in metformin and GLP-1 inhibitors, and calls out a real research gap for both mild and severe patients.
Any therapy takes about three months to assess, given the waxing and waning nature of the disease, and that trial also becomes the entry point for biologic approval. But Micheletti cautions against overdoing the step-up: 'You don't need to prove to yourself that every antibiotic you can think of doesn't work.' He cites a claims-database study showing that while about one third of HS patients have moderate-to-severe disease and would be eligible for a biologic, only 1.8% were actually receiving one — a treatment gap on top of the diagnosis gap. His bottom line: earlier is better, and don't dilly dally.
Managing Expectations and the Fearful Patient
Unlike psoriasis, where near-complete clearance is common, HS response is more modest. Micheletti hopes for a day when HiSCR 90 and 100 are routine, but the field isn't there yet. His framing is that treatment will start moving things in the right direction, and while he can quote general efficacy data, the individual response is unknown until they try. His signature reassurance: 'I'm never out of ideas' — there's always a plan B, C, or D, whether that's adjusting the dose or switching mechanism of action. He finds HS patients will stick it through when they trust the effort is real.
For fearful patients — needle-phobic or worried about immunosuppression and long-term side effects — Micheletti recommends asking directly what their reservations are and meeting them where they are. He uses a scale analogy, weighing a rare event like TB reactivation (which is screened for before starting and annually) against the daily impact of the disease, which usually makes it an easy call. He believes it's okay to be vociferous and tell a patient this is what he really thinks they need to do, while giving some patients the extra three months they need to prove it to themselves.
On the inevitable 'when can I stop?' question, Micheletti is honest that HS is a chronic condition without a cure, but like other autoimmune diseases it can burn out over time — he just can't predict when. He looks for a therapy that is effective, safe, and well tolerated, because patients will stay on it long term. If someone is doing very well for a long time, backing off can be discussed on a case-by-case basis. As the hosts note, that's a good problem to have.