Early HS Treatment May Prevent Scarring in Patients With Skin of Color

Hidradenitis suppurativa (HS) is typically diagnosed 7 to 10 years after symptoms begin. By then, many patients, particularly those with skin of color, have already developed tunnels and scarring. Tiffany Mayo, MD, MSc, associate professor of dermatology at the University of Alabama at Birmingham, urged clinicians to recognize and treat the disease within that window at the Skin of Color Update 2026 in New York, New York.¹

Shortening HS Diagnostic Delay

HS affects an estimated 0.1% to 4.0% of the US population, likely an underestimate, and is twice as common in Black patients and in women, Mayo said. The diagnostic delay is well documented. In a study of 517 patients with HS across 24 countries, the mean diagnostic delay was 7.2 years, compared with 1.6 years among 516 patients with psoriasis. Nearly three-quarters of patients with HS (73.3%) waited more than 2 years for a diagnosis, and women and those with moderate or severe disease were more likely to face a significant delay.²

To catch it sooner, Mayo recommends a simple screening question: Has the patient had at least 2 boils in the past 6 months? A yes likely points to HS. Skin of color adds specific challenges. Hypertrophic and keloidal scarring are more common. Hyperpigmentation can also make erythema harder to see, which complicates judging when a patient is flaring. Patients care about these sequelae too; once their disease improves, Mayo said, their first questions are usually about clearing scars and pigment. She also encouraged clinicians to correct common misconceptions with every patient: HS is not an infection and is not caused by poor hygiene.¹

“Obesity is not the reason for HS. It is a part of your HS, and HS is not just a skin disease. It is an inflammatory systemic disorder,” Mayo said.

HS Window of Opportunity

That window is the period when a patient is inflamed but has not yet developed scarring, and it may close sooner than clinicians expect. A patient with multiple erythematous nodules is often labeled early stage and given 3 months of doxycycline, with follow-up in 6 to 9 months. Mayo said that approach likely misses the chance to prevent scarring, and such patients may warrant a biologic. Antibiotics should be reserved for early disease and flare management. If a patient still needs them after 3 months, an advanced therapy should already have been started.

“I don’t even want you to think of the antibiotics as a long-term treatment for HS. They are not,” she said.

Adjunctive and Advanced HS Options

Mayo described oral contraceptives and spironolactone as effective adjunctive therapies in women. She typically keeps spironolactone at 75 to 125 mg because of hypotension concerns, though it can go up to 200 mg. Metformin, which downregulates fibrosis, deserves a second look, and finasteride can help some men. Retinoids, phosphodiesterase 4 inhibitors, and glucagon-like peptide-1 receptor agonists can also serve as adjuncts.

Among targeted therapies, adalimumab works for some patients and is often covered as first-line. Off-label infliximab at 7.5 to 10 mg/kg every 4 weeks is a mainstay for advanced disease. Secukinumab has shown sustained efficacy through 4 years, and bimekizumab has 3-year data showing sustained HiSCR50 responses.

Emerging options include:

• povorcitinib, an oral agent with sustained efficacy through 54 weeks
• an anti-TL1A agent that targets both inflammation and fibrosis
• IL-1 inhibition
• an investigational IL-17A/F inhibitor with deepening responses at 52 weeks

European guidelines already outline management by severity, and Mayo said she hopes US guidelines will follow soon. Finally, she reminded clinicians to address vaccinations for patients starting immunosuppressive therapy. She also urged them to refer patients to clinical trials, which are enrolling more patients with skin of color.

References

1. Mayo T. Hidradenitis suppurativa in skin of color: disease state update. Presented at: Skin of Color Update 2026; October 9-11, 2026; New York, NY.
2. Saunte DM, Boer J, Stratigos A, et al. Diagnostic delay in hidradenitis suppurativa is a global problem. Br J Dermatol. 2015;173(6):1546-1549. doi:10.1111/bjd.14038