From 'Terrified to Treat' to a Toolbox Full of Options
In recognition of Hidradenitis Suppurativa Awareness Month, PA Shanna Miranti sat down with her co-host and in-house HS expert PA Buchi Neita to walk through how far the field has come. Neita is candid that she wasn't always a fan of treating HS: early in her career she was, in her words, terrified of it because there were so few effective options and nothing was FDA approved. The shift over the last decade, she says, has been phenomenal.
Much of the episode draws on a comprehensive review Neita co-wrote with nurse practitioner Patricia Delgado (owner of Sunrise Skin and Wellness in the St. Pete area) for the Journal of Dermatology for PAs and NPs (JDMPPA), titled 'What's in Your HS Toolbox.' Both hosts encourage listeners to read the full article for a deep dive into past and current therapies, plus practical topics like wound-care supplies clinicians don't always think about.
Nail the Diagnosis Early — and Call It What It Is
Neita's go-to screening question is simple: In the past six months, have you had recurrent (more than two or three) painful boils in the underarms, below the breasts, or the groin? A 'yes' means it's almost certainly HS. She notes this single question carries a 90-plus percent sensitivity for diagnosis, making it easy enough for any APP new to derm to use chair-side.
The most common diagnostic mistake, Neita says, is calling it everything else — folliculitis, ingrown hairs, or infections. Patients are still being told they have staph infections when they don't. Her Advice: don't drag out the diagnosis. Ask the question, and if the answer is yes, call it HS up front and start therapy early. Miranti reinforces the theme that runs through the whole episode: catch it early to stop that snowball from rolling down the hill.
Topicals and Orals for Early and Mild Disease
For early, mild cases, Neita and Delgado's article covers topical options starting with over-the-counter cleansers — benzoyl peroxide at varying percentages, chlorhexidine wash (which can be irritating), and sodium hypochlorite cleansers. Miranti says she now recommends the sodium hypochlorite cleanser more, given data on its efficacy and its help with secondary bacterial, yeast, and fungal overgrowth.
Beyond cleansers, Neita uses clindamycin regularly but has had little success with resorcinol. She's most excited about two topicals already on the market being used off-label: topical ruxolitinib (used for atopic dermatitis and vitiligo), which shows decent efficacy in early HS, and topical clascoterone, given the disease’s hormonal component. She also mentions topical glycopyrronium/glycopyrrolate to reduce sweating in affected areas.
Orally, tetracycline-class antibiotics remain a mainstay for both anti-inflammatory effect and secondary infections. Neita highlights hormonal and metabolic modulators as increasingly attractive: spironolactone in female patients, metformin for higher insulin resistance in HS, and GLP-1 agonists, where she’s seen several patients do well in combination or even as isolated therapy—with the added benefit of weight loss and improved confidence.
When to Move to Systemics and Biologics
Neita's rule of thumb: once a patient goes beyond topicals and oral antibiotics, it's time for systemic therapy. Documented Hurley stage 2 or 3 — scarring, sinus tracts, recurring abscesses and nodules — makes them candidates for biologics. She cautions that Hurley staging doesn't always match severity; a patient with numerous inflammatory nodules but no sinus tracts still deserves aggressive treatment.
She typically bypasses TNF inhibitors unless insurance forces a step through a branded TNF or biosimilar, noting that real-world results didn't match the excitement when the first agent was approved. Her favorite class to prescribe is the IL-17 inhibitors, which she calls highly effective in clinical trials for severe disease. Again, she stresses treating early—before severe sinus tracts and scarring develop—to change the course of the disease.
Looking ahead, Neita is most excited about systemic JAK inhibitors, citing early data and phase 3 trials. She also flags a Bruton tyrosine kinase inhibitor in the pipeline. The reality, she notes, is that HS often requires stacking therapies rather than a one-and-done approach, and the arrival of JAKs reinforces that HS is a systemic inflammatory disease, not just a follicular or cutaneous one.
Procedures, Lifestyle, and the Whole Patient
Neita urges clinicians to move away from incision and drainage in favor of deroofing. If you're not comfortable with a major deroofing, start with a mini deroofing: punch out the abscess, drain it, and curette the inside. She cites lower recurrence rates than I&D. CO2 laser can help where available, and surgical excision remains an option—but find a surgeon comfortable with HS and control the inflammation first. She also points to laser hair removal (an idea he credits to Dr. Jeanette Okoye) as a way to potentially reduce progression, especially for axillary disease, and encourages writing letters and using AI tools to pursue coverage.
Two often-overlooked areas: wound care and pain management. Patients often source their own wound care — sometimes inappropriate or expensive — so clinicians should have that conversation and point patients toward coverage options. For pain, Neita prescribes topical BLT (benzocaine/lidocaine/tetracaine) applied about 30 minutes before intralesional Kenalog injections, still uses local anesthesia for deroofing, and mentions OTC 1% diclofenac gel for inflammatory lesions, referring severe cases to pain management.
Both hosts emphasize the psychosocial burden — higher rates of anxiety, depression, disability, and missed work. Neita, who is certified in lifestyle medicine, provides handouts on anti-inflammatory diet, exercise, sleep, and smoking cessation. Neither host expects all of this in one visit; Miranti notes the first visit is about giving patients hope and building trust, layering in counseling over subsequent visits.