The Do’s and Don’ts of Managing Pediatric Hidradenitis Suppurativa

Pediatric hidradenitis suppurativa (HS) presents unique diagnostic, therapeutic, and psychosocial challenges that differ in important ways from adult HS. Delayed recognition, hesitation to escalate therapy, and underappreciation of comorbidities can allow early disease to progress during a critical window of physical and emotional development. Here we look at some practical, evidence-based “Do’s and Don’ts” for clinicians caring for children and adolescents with HS.

Diagnosis and Early Recognition

DON’T assume it can’t be HS because a patient is “too young.” While it is uncommon for HS to occur prior to puberty, HS does happen in healthy prepubertal children and has even been reported in as young as toddlers with certain genetic syndromes. The average age of diagnosis in an international meta-analysis was 11.3 years, but the average age of diagnosis was 14.0 years.¹ Approximately half of adult patients report initial onset of their HS symptoms between ages 10 to 21.² Bacterial cultures and continued follow-up are important to distinguish HS from other conditions.

DON’T rely solely on adult-derived HS diagnostic criteria. Zouboullis et al proposed a requirement of ≥2 episodes of characteristic lesions in characteristic sites within 6 months to make the diagnosis.³ This has high specificity and sensitivity in adults. However, in a large pediatric cohort, about 43% of children diagnosed with HS didn’t meet those criteria at presentation, with almost all being due to the recurrence interval criterion.⁴ Increasing the time frame of recurrence to 1 year raises the sensitivity to 72%. 

DO screen for HS in patients with severe acne. Children and young adults with cystic acne have a higher rate of HS than the general population. It is important to ask whether they have “acne” in any areas outside of the face, chest, and back, especially if you are discussing isotretinoin as a treatment. Patients are often embarrassed to mention areas of involvement such as the axillae or groin, and they may assume that it doesn’t matter because this will also go away with their acne treatment. Because HS does not typically respond well to isotretinoin, additional therapies will likely be needed.

DO check for signs of immune dysfunction. While most patients with recurrent inflammatory lesions in skin folds have HS, a small percentage could have an inborn error of immunity that mimics this condition. Ensure that patients do not have red flags such as recurrent fevers with or without flares, frequent sinopulmonary infections, or unusual pathogens such as Serratia or Burkholderia. Patients with any of these, or who have refractory or worsening disease with targeted HS therapy, should be referred to Immunology for a comprehensive work-up.

Comorbidity Screening

DO screen early for comorbidities.⁵ The high comorbidity burden of HS in adults is mirrored in children. Metabolic, hormonal, autoinflammatory, and psychiatric conditions should all be screened for as early as possible when the diagnosis is made. Identifying these comorbidities is important, as it may guide your treatment choices for the patient’s HS. This could require partnering with primary care or adolescent medicine to manage these comorbidities.

DON’T stop screening for comorbidities after the first visit. Patients should be screened at least annually for metabolic syndrome, inflammatory bowel disease, depression, anxiety, smoking, and other associated conditions. This is especially important when it comes to mental health screening. One study that followed 153 patients showed that the prevalence of psychiatric comorbidities such as anxiety and depression increased over time, which was not seen with somatic comorbidities.⁶

Topical Therapies

DO start topical therapy for children with mild or early disease.⁷ Patients with infrequent flares or primarily open comedones on exam without frequent inflammatory lesions can benefit from antiseptic washes to prevent flares. There is no evidence for one topical antiseptic solution over another, and some patients may respond well to one when another has failed. Topical clindamycin, tretinoin, or resorcinol may also be good options for prevention or flares.

DON’T stop at topicals alone if there is recurrent drainage, tunnels, or scarring. Withholding or delaying systemic therapy due to age alone, when similar disease severity would be treated with systemic therapy in an adult, will lead to more disease progression and increased morbidity over the life of the patient. Even in mild disease, you should have a very low threshold for escalating therapy if there is inadequate response to topicals.

Systemic Antibiotics and Oral Therapies

DO use systemic antibiotics for mild to moderate HS when indicated.7 Doxycycline can be used for all patients 8 and older. It can even be used safely by patients of any age for up to 21 days without risk of tooth discoloration.⁸ Alternate antibiotics include clindamycin or minocycline for those who cannot tolerate doxycycline. Aim for a full trial of 8 to 12 weeks and then reassess. If disease persists after an adequate trial of antibiotics, escalate therapy.

DO consider hormonal therapies for women with premenstrual flares. Especially in pediatrics, patients may not recognize an association with their period, and it can be helpful to have patients track their flares and menses to determine a relationship. Combined oral contraceptive pills (COCs) or spironolactone may be effective for these patients, though it takes 3 to 6 months to see efficacy. Avoid COCs in patients who have not had at least 1 year of menses or who have thrombotic risk factors. Adolescents need 30 mcg to 35 mcg of estrogen in COCs to reduce the risk of osteoporosis.⁹ Continuous COCs, meaning patients skip the placebo pills and continue directly to their next pack, are an especially good option for patients who do not want to have a period. In these cases, a monophasic pill is preferred over triphasic to reduce the risk of breakthrough bleeding. Keep in mind that progestin-only contraceptives worsen HS.¹⁰ Patients on these medications may warrant a discussion regarding alternate contraceptive options if their disease cannot be controlled with other therapies. 

DON’T assume patients know how to assess response to treatment. Tunnels may not fully respond to any medical management and may need procedural intervention to clear these recurrent areas. Help manage expectations by telling patients what to look for to determine if their inflammation is coming under control: decreased number of new lesions, decreased duration and intensity of flares, etc. If they are looking to be completely clear, they may miss the positive effects of their treatment. This can lead to discontinuing therapies that are actually helpful, delay in surgery thinking disease inflammation is poorly controlled, or escalating to higher-risk therapies that may not be needed.

DON’T rely solely on antibiotics long-term without additional interventions (eg, biologics, hormonal therapy, procedures, lifestyle modifications). While antibiotics alone may help some patients gain control of disease or enter remission, they are unlikely to maintain this improvement without a maintenance therapy. Combination, multimodal treatment aimed at managing triggers and comorbidities is often needed for sustained control.  

Additional Procedural Considerations

DO consider deroofing in your pediatric patients. Any lesion that is recurrent at the same exact site can benefit from deroofing. With appropriate management of expectations, adolescents can typically tolerate this procedure in the office.¹¹ Distraction techniques such as listening to music or having a barrier that blocks the surgical site from their view may be helpful. Adolescents and adults feel similarly about their deroofing outcomes, with 77.8% and 76% respectively reporting they were “extremely satisfied” or “moderately satisfied.”^12,13 Make sure families feel supported during the post-operative period, including adequate instruction and preparation for wound dressings.

DON’T let patients see the needle when injecting intralesional steroid. Keeping the syringe out of sight until just before the procedure (in a pocket or behind a piece of gauze) will lessen anxiety. Use adjunctive pain control therapies such as topical numbing creams, ice, and distraction.

Biologic Therapy

DO consider systemic biologic therapy for adolescents with moderate-to-severe or refractory HS. Adalimumab is the only US Food and Drug Administration (FDA)-approved biologic medication for children ages 12 to 17 with HS. While Hurley staging is sometimes used as an adjunct for disease severity, patients with Hurley stage 1 disease may still be considered “moderate” on some scales. For example, the HS-Physician’s Global Assessment score (HS-PGA) qualifies the presence of five or more inflammatory nodules as moderate even in the absence of scarring or tunnels.¹⁴

DO consider biologics with other pediatric indications if adalimumab fails. It is easier to argue for coverage of medications with at least some safety data in children. Of the two other therapies currently approved for HS in adults, secukinumab is approved for psoriatic arthritis down to age 2, whereas bimekizumab does not yet have any pediatric indications. The availability of biosimilars for infliximab, approved for Crohn’s disease and ulcerative colitis down to age 6, may also be more appealing to insurance companies compared to other biologics given their relatively lower price.

DON’T delay escalation when disease is persistent, scarring, or affecting quality of life.  There is a “window of opportunity” for treating HS, where treatments including biologics work best prior to the formation of significant scarring or sinus tracts.¹⁵ Early disease control is key to altering the trajectory of disease. Delays in treating HS result in poorer response to adalimumab.¹⁶

DON’T rule out biologics for patients with Down syndrome. These patients have an earlier age of disease onset due to a combination of genetic and immune factors, yet are often undertreated.¹⁷ This may be due to hesitancy given the increased risk of leukemia in patients with Down syndrome, especially at younger ages. However, adalimumab does not increase leukemia risk specifically. The risk of lymphoma in patients with Down syndrome is estimated to be about the same as the general population, if not lower.¹⁸ Existing data support that adalimumab and other biologics are safe and well-tolerated in this patient population.^19,20 For patients with needle phobia or developmental delay with behavior difficulties, child life specialists or psychologists can be helpful in managing these concerns. Biologics with an overall lower frequency of injections may also be considered.

Supportive Management

DO talk about school with patients and their parents. You as the clinician have a lot of power, and parents may not bring up their concerns as they may not think it is relevant. It is often helpful to write a letter to the school explaining what HS is and the impact it may have on the patient. Families should also be advised to discuss the possibility of a 504 plan if they are in public school. According to the US Department of Education, a student is eligible for a 504 plan if they have “a physical or mental impairment that substantially limits one or more major life activities.” Having a 504 plan provides accommodations to allow the HS patient to access the same curriculum and learning opportunities as their peers. This may include permission to use the restroom without a hall pass in case an abscess bursts in class, permission to sit out of physical activity without needing to explain why, and a plan for making up missed work due to painful flares. 

DON’T underestimate the psychosocial impact of HS on adolescents. Embarrassment, stigma, disrupted school or social life, body-image issues, and depression can be major contributors to reduced quality of life in pediatric HS. One study showed that the average Skindex-Teen score for adolescents with HS was 45.7 (maximum 84).²¹ For comparison, psoriasis and atopic dermatitis are about 21.1 and 29.4, respectively.²² Quality of life impairment also worsens with Hurley stage, underlining the importance of adequately treating early disease.

Long-Term Management

DO counsel patients and families early about the chronic nature of HS. This is likely the first chronic illness the patient has been diagnosed with, and it may be a struggle to come to terms with that knowledge. Ensure patients and families understand that it may require long-term therapy, combination treatments, regular wound care, and lifestyle adjustments. Early realistic expectation setting improves adherence.

DON’T ignore mechanical triggers or exacerbating factors. While medical and surgical interventions are what we are used to focusing on, environmental and lifestyle factors can have a huge impact on HS as well. Friction, occlusion, heat, sweat, and smoking may all play a role to varying degrees. Encourage mitigating strategies such as seamless undergarments, or clothing that is loose, sweat-wicking, or breathable. Obesity may worsen friction and sweating, though there is little evidence that losing weight consistently improves HS. Dietary modifications and low friction exercises (eg, Pilates, swimming) may be helpful for some patients.²³

1. Xiong G, et al. Prevalence, age of onset, age at diagnosis, and family history of hidradenitis suppurativa in pediatric populations: a systematic review and meta-analysis. Pediatr Dermatol. 2025;42(6):1142-1148.

2. Molina-Leyva A, Cuenca-Barrales C. Adolescent-onset hidradenitis suppurativa: prevalence, risk factors and disease features. Dermatology. 2019;235(1):45-50.

3. Zouboulis CC, et al. Hidradenitis suppurativa/acne inversa: criteria for diagnosis, severity assessment, classification and disease evaluation. Dermatology. 2015;231(2):184-190.

4. Kittler NW, et al. Evaluation of hidradenitis suppurativa diagnostic criteria in pediatric patients. JAMA Dermatol. 2022;158(12):1404-1408.

5. Mohsen ST, et al. Prevalence of comorbidities among pediatric patients with hidradenitis suppurativa: a meta-analysis. JAMA Dermatol. 2025;161(8):805-812.

6. Tiri H, et al. Somatic and psychiatric comorbidities of hidradenitis suppurativa in children and adolescents. J Am Acad Dermatol. 2018;79(3):514-519.

7. Alhusayen R, et al. North American clinical practice guidelines for the medical management of hidradenitis suppurativa in special patient populations. J Am Acad Dermatol. 2025;92(4):825-852.

8. Stultz JS, Eiland LS. Doxycycline and tooth discoloration in children: changing of recommendations based on evidence of safety. Ann Pharmacother. 2019;53(11):1162-1166.

9. Scholes D, et al. Oral contraceptive use and bone density in adolescent and young adult women. Contraception. 2010;81(1):35-40.

10. Perlmutter JW, et al. The use of hormonal therapies in patients with hidradenitis suppurativa: a systematic review. J Cutan Med Surg. Published online June 14, 2025.

11. Leszczyńska M, et al. Surgical deroofing in pediatric patients with hidradenitis suppurativa. Pediatr Dermatol. 2022;39(3):502-505.

12. Ravi S, et al. Patient impressions and outcomes after clinic-based hidradenitis suppurativa surgery. JAMA Dermatol. 2022;158(2):132-141.

13. Haller CN, et al. Adolescent satisfaction after deroofing surgery for hidradenitis suppurativa. Pediatr Dermatol. Published online October 6, 2025.

14. Garg A, et al. Development and initial validation of the HS-IGA: a novel hidradenitis suppurativa–specific investigator global assessment for use in interventional trials. Br J Dermatol. 2022;187(2):203-210.

15. Martorell A, et al. Management of patients with hidradenitis suppurativa. Actas Dermosifiliogr. 2016;107(suppl 2):32-42.

16. Marzano AV, et al. Evidence for a window of opportunity in hidradenitis suppurativa treated with adalimumab: a retrospective, real-life multicentre cohort study. Br J Dermatol. 2021;184(1):133-140.

17. Lam M, et al. Hidradenitis suppurativa and Down syndrome: a systematic review and meta-analysis. Pediatr Dermatol. 2020;37(6):1044-1050.

18. Hasle H. Pattern of malignant disorders in individuals with Down syndrome. Lancet Oncol. 2001;2(7):429-436.

19. Dao DD, et al. Demographics and treatment trends in the largest cohort of patients with Down syndrome and hidradenitis suppurativa. Int J Dermatol. 2024;63(8):e180-e181.

20. Mallela T, et al. Management of hidradenitis suppurativa in special populations: a narrative review. Dermatol Ther (Heidelb). 2025;15(8):1985-1998.

21. McAndrew R, et al. Quality of life in hidradenitis suppurativa: a cross-sectional study of a pediatric population. J Am Acad Dermatol. 2021;84(3):829-830.

22. Smidt AC, et al. Development and validation of Skindex-Teen, a quality-of-life instrument for adolescents with skin disease. Arch Dermatol. 2010;146(8):865-869.

23. Dagenet CB, et al. Lifestyle modifications and nonpharmacological treatments in hidradenitis suppurativa. Dermatol Clin. 2025;43(2):273-284.

Colleen Cotton, MD

Assistant Professor of Dermatology and Pediatrics, George Washington University School of Medicine and Health Sciences

Pediatric dermatologist, Children’s National Hospital, Washington, DC