A New Chapter in Hidradenitis Suppurativa Care Starts Here

Estimated reading time: 15 minutes

Key Takeaways

• IL-17 inhibitors, such as secukinumab, bimekizumab, and sonelokimab, are transforming the treatment of HS.
• Treatment stacking—combining biologics, procedures, and lifestyle changes—yields deeper, lasting control.
• Precision strategies, utilising markers such as CRP, guide smarter biologic choices and earlier intervention.
• Updated guidelines emphasise the early use of biologics, pain and quality-of-life measures, and surgical collaboration.
• Lifestyle levers—such as nutrition, friction reduction, smoking cessation, and mental health support—are essential.

Introduction: A New Chapter in HS Care Starts Here

The first time Tasha told me about her “boils,” she kept her voice low, as if she were confessing a secret. She’d missed work again because of pain in her armpit—one of those deep, hot lumps she’d learned to “wait out.” It wasn’t until one finally ruptured and demanded an emergency visit that someone said the name out loud: hidradenitis suppurativa.

If you’ve had to spell that out for someone—hidradenitis suppurativa, or HS—you probably also know how frustrating and isolating this disease can be. HS is a chronic inflammatory skin condition that looks like acne’s angrier cousin but behaves more like a wildfire. It can flare in areas where skin rubs against skin—such as the armpits, groin, under the breasts, and buttocks—forming painful nodules, abscesses, tunnels (sinus tracts), and scars. It shows up uninvited. It makes clothing choices complicated. It changes social plans. It can upend your self-image and stir a sense of shame (read more in The Power and Peril of Shame).

And until recently, hidradenitis suppurativa management often felt stuck in the past. People bounced between antibiotics, antiseptic washes, and painful procedures while being told there wasn’t much else to try. The 2019 treatment guidelines—while helpful at the time—couldn’t foresee what was about to happen next.

Here’s the surprising and hopeful truth: the landscape has changed fast. We’re at the beginning of a new era in HS care, powered by biologics that target key inflammatory pathways (especially IL-17), more innovative surgical approaches, and a growing movement toward “treatment stacking”—combining the right treatments at the correct times to get better, faster control. If you’ve been living with HS, this matters deeply to you. It means more options, earlier intervention, and a realistic hope that things can improve.

Let’s discuss what’s new, its implications for your day-to-day life, and how you and your care team can confidently navigate the latest advancements in hidradenitis suppurativa management.

Core Concepts and Mechanisms: What’s Actually Driving HS—and Why IL-17 Is a Star Player

Let’s break down HS to its core components. Imagine your hair follicles as tiny, delicate chimneys. In HS, those chimneys get clogged. Pressure builds. The walls weaken and rupture, spilling debris and bacteria into the surrounding skin. Your immune system rushes in like firefighters, but the alarms keep getting pulled. Over time, you get repeat fires—painful nodules, abscesses, sinus tracts, scars.

But why do those chimneys clog and collapse in the first place?

• Genetics and biology: Family history can influence follicular structure and the immune system’s thermostat.
• Immune dysregulation: HS involves TNF-alpha, IL-1, and the IL-17/Th17 pathway. IL-17A and IL-17F are headline acts in HS inflammation.
• Microbiome: Biofilms and shifts in the local microbial ecosystem keep the immune system on simmer.
• Mechanical friction: Skin-on-skin areas (armpits, groin) are hotspots—friction, sweat, and occlusion stoke the flames.
• Hormones and metabolism: HS flares around menstrual cycles and links to PCOS and metabolic syndrome. Insulin resistance and obesity act like kindling (see Healthy Eating for Kids: 8 Fun, Science-Backed Tips That Actually Work).

Think of the IL-17 pathway like a key wire in a smoke detector. When IL-17 signals flood the scene, they amplify inflammation. That’s why IL-17 inhibitors are such a breakthrough.

Meet the Biologics Changing the Game

• Secukinumab (Cosentyx): An IL-17A inhibitor approved for moderate-to-severe HS in the US and Europe since 2023. It locks onto IL-17A, dialling down one of the most potent inflammatory triggers in HS (AJMC).
• Bimekizumab: Blocks both IL-17A and IL-17F. In recent analyses, it’s emerging as a top performer for achieving HiSCR-50. Late-stage trials demonstrate efficacy and safety comparable to, or better than, adalimumab (EMJ Reviews).
• Sonelokimab: A nanobody targeting IL-17A/F. Now in phase III trials, including studies in adolescents—a sign the field is serious about early care (SimcoDerm 2025 Research Summary).
• Adalimumab (Humira): The first FDA-approved HS biologic, targeting TNF-alpha. It set the benchmark but leaves room for alternative pathways.

Other pipeline candidates include lutikizumab (IL-1A/B), spesolimab (IL-36 receptor), izokibep (a unique IL-17A inhibitor), and povorcitinib (an oral JAK1 inhibitor, phase III in 2025; DelveInsight Drug Pipeline Overview).

Precision Medicine Is Moving from Buzzword to Bedside

One exciting shift is tailoring decisions to your biology and pattern. For example, high CRP often links to lower response rates to adalimumab. If your CRP is elevated, your clinician might favour an IL-17 inhibitor first—saving time, suffering, and scars.

Precision clues include:

• Phenotype: Nodular vs. extensive tunnels vs. area predilection guides intervention choice.
• Comorbidities: PCOS, obesity, smoking, depression, and IBD shape medication, lab monitoring, and timing of surgery.
• Hormonal patterns: Cycle-linked flares may call for hormonal therapies (e.g., spironolactone).
• Ultrasound findings reveal hidden tunnels—sometimes prompting deroofing and the use of additional antibiotics.

Treatment Stacking: Building a Strategy, Not a Single Shot

If HS is a wildfire, monotherapy is one hose. Treatment stacking combines tools—biologic + antibiotic burst + intralesional steroid + minor surgery + lifestyle tuning—so the flames die out and stay out.

• Start an IL-17 inhibitor and plan deroofing for persistent tunnels.
• Use short antibiotic courses for acute flares while maintaining biologic control.
• Add hormonal therapy for cycle-dependent disease.
• Introduce metformin for the treatment of insulin resistance and weight support.
• Coordinate pre- and post-op biologic therapy to lower recurrence risk.

Updated Guidelines: From 2019 to Now

The 2019 HS guidelines were a milestone, but predated today’s biologics and early escalation mindset. New frameworks highlight:

• Earlier biologic use for moderate disease.
• IL-17 inhibitors as core options alongside adalimumab (AJMC).
• Precision cues, such as CRP, can guide the choice of first-line biologics.
• Emphasis on pain, quality of life, and mental health (Natural Remedies for Anxiety).
• Routine surgical partnership and treatment stacking.

Treatment and Management Approaches: The Modern HS Playbook

Here’s a customizable roadmap. Every HS journey is personal, but these pillars are consistent.

1. Diagnosis and staging: Confirm HS, stage with Hurley and IHS4. Consider ultrasound. Check CRP/ESR/glucose/lipids. Assess comorbidities.
2. Basics: Antiseptic washes, topical clindamycin, intralesional steroids, friction control, wound care.
3. Antibiotics: Tetracyclines early, followed by clindamycin and rifampin as a bridge; reserve rotating combinations for refractory cases.
4. Hormonal/metabolic adjuncts: Spironolactone, OCPs, finasteride, metformin, weight support, smoking cessation (Understanding the Psychology of Habits).
5. Biologics: Adalimumab; secukinumab (IL-17A; approved 2023); bimekizumab and sonelokimab in late-stage development; JAK inhibitors; IL-1/IL-36 agents.
6. Surgery and procedures: Deroofing, wide local excision, laser (Nd: YAG, CO2); stack with biologics for best outcomes.
7. Pain and mental health: NSAIDs, topical analgesics, gabapentin for neuropathic pain; therapy and support groups for mental well-being.

Prevention and Practical Applications: What You Can Do Starting Today

If daily HS maintenance feels like its own job, here are evidence-informed strategies.

Conclusion and Future Outlook: Where HS Care Is Heading—and How to Ride the Wave

HS care is evolving fast. Here’s the distilled truth:

• IL-17 inhibitors have opened new doors (AJMC).
• Precision-guided choices using CRP and phenotype are now a real practice.
• Treatment stacking combines biologics, surgery, and adjuncts for durable remission.
• Updated guidelines emphasise the early use of biologics, holistic care, and surgical partnerships.
• Safety profiles are reassuring; next steps focus on access and head-to-head trials.

You deserve a plan worthy of your life. HS is treatable, and the tools—and the mindset—are on your side.

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