Combination Therapy, Biologics, and Surgery Redefine HS Care in 2026

Management of hidradenitis suppurativa (HS) continues to evolve rapidly, with clinicians now approaching the disease as a complex systemic disorder requiring coordinated medical, surgical, and supportive strategies. In a Maui Derm Hawaii 2026 session, Vivian Shi, MD, director of the Hidradenitis Suppurativa Specialty Clinic and professor of dermatology at the University of Washington, Seattle, delivered practical guidance spanning early detection, topical and systemic therapy, biologics, surgery, and patient-centered treatment planning, offering clinicians a roadmap for treating HS across disease stages.¹

A central theme was the growing recognition of HS as a multisystem inflammatory disease rather than a purely dermatologic condition. Routine evaluation includes screening for metabolic and cardiovascular risk factors, rheumatologic disease, hormonal abnormalities such as polycystic ovary syndrome (PCOS) and insulin resistance, and the psychological burden linked to chronic pain and drainage. Shi also highlighted genetic links, noting data indicating patients with trisomy 21 have a higher HS risk,² prompting recommendations to actively screen patients with Down syndrome, who often develop earlier and more severe disease.¹

“Traditionally, when you see an HS patient, you should screen them for PCOS or diabetes,” Shi said. “But trisomy 21 is the only condition where you should reverse screen, meaning if you have a trisomy 21 patient sitting in front of you, you should screen them for HS, because you're 5 times more likely to have HS than the general public.”

Topical therapy remains foundational but challenging because HS commonly affects occluded, high-drainage areas already covered by dressings. Rather than complex regimens, Shi recommended alternating topical agents to improve adherence. Standard options, including topical clindamycin, benzoyl peroxide (BPO), and chlorhexidine washes, remain common, although combining BPO with topical dapsone may cause temporary yellow skin discoloration, a reversible but potentially distressing effect if patients are not forewarned.

Topical resorcinol also received a strong endorsement as an effective but often compounded option in the US, offering keratolytic and anti-inflammatory effects and outperforming clindamycin in small studies assessing lesion control and quality of life.

“Clindamycin is pretty good for short-term flare control for these milder patients, but resorcinol is really kind of the denominator that helps them day to day, to help unplug the follicle and prevent inflammatory response,” Shi said.

Newer approaches include off-label use of ruxolitinib cream (Opzelura; Incyte), a topical Janus kinase inhibitor showing promise in reducing lesion counts as well as HS-related pain and itch, with phase 3 data expected soon.

Systemic antibiotics continue to play an important role, increasingly as combination or bridging therapies rather than standalone treatments, Shi explained. Severe flares may require intravenous (IV) ertapenem, particularly when rapid control is needed before surgery or while awaiting biologic access. Combination oral regimens, including clindamycin plus rifampin or multidrug protocols known as the “Three Musketeers,” appear more effective than monotherapy, especially in highly draining disease. Using antibiotics alongside biologics during induction also produces better early responses than biologics alone.

To improve tolerability, Shi introduced an “Oral Medication March,” in which medications are added sequentially rather than all at once, making it easier to identify intolerable agents while reducing dropout due to pill burden.

Hormonal and metabolic therapies are increasingly incorporated, even when patients lack obvious hormonal triggers. Spironolactone and oral contraceptives are widely used in women, while finasteride or dutasteride may benefit men and postmenopausal women. Metformin remains common, and glucagon-like peptide-1 receptor agonists are gaining attention, as weight loss and metabolic improvements may reduce inflammatory signaling, although rapid weight loss can temporarily worsen disease because of increased skin friction from laxity.

Biologic therapy continues to expand, with adalimumab, secukinumab, and bimekizumab now available in various markets. For severe Hurley stage III disease, however, Shi emphasized early use of high-dose IV infliximab, often combined with methotrexate, to improve durability. Emerging data suggest HS involves both T-cell and B-cell pathways, driving development of Bruton tyrosine kinase inhibitors, spleen tyrosine kinase inhibitors, and next-generation interleukin-17–targeted therapies. Treatment goals are also shifting, with trials increasingly targeting HiSCR75 or higher instead of the older HiSCR50 benchmark.

Despite medical advances, surgery remains essential in severe disease, as medications reduce inflammation but do not eliminate biofilm-filled tunnels that drive recurrence. Once inflammation is controlled, a 4-to-8-week window allows for more effective surgical intervention, while intralesional corticosteroid injections and office-based procedures remain valuable for localized control.

Overall, the “Hidradenitis Suppuritiva Update 2026” session underscored a new treatment paradigm: HS care in 2026 requires early diagnosis, systemic screening, combination medical therapy, and strategic surgical intervention, all tailored to reduce disease burden and improve long-term patient quality of life.

References

1. Shi V. Hidradenitis Suppurativa Update 2026. Presented at: Maui Derm 2026; January 25-29, 2026; Maui, HI.
2. Garg A, Strunk A, Midura M, Papagermanos V, Pomerantz H. Prevalence of hidradenitis suppurativa among patients with Down syndrome: a population-based cross-sectional analysis. Br J Dermatol. 2018;178(3):697-703. doi:10.1111/bjd.15770