Mirza Ali Alikhan, MD

Ask the Experts
Mirza Ali Alikhan, MD

Hidradenitis suppurativa

Practice Community
Cincinnati, OH
Hospital and Institute Affiliations
Assistant Professor of Dermatology, University of Cincinnati College of Medicine
Number of Patients Seen in a Week
Approximately 100 per week
Practice Niche


Since the average interval from onset of symptoms of Hidradenitis suppurativa to diagnosis is 7.2 years, what, based on your experience, should raise suspicion of Hidradenitis suppurativa among clinicians so that patients may receive the most appropriate treatment?


Classic areas for Hidradenitis suppurativa include the armpits, under the breasts, the groin, and in between the buttocks. There may be early signs of Hidradenitis suppurativa we can investigate so we can start the patient on treatment. It is important to catch Hidradenitis suppurativa earlier and give it a name. I cannot tell you how many times I still see patients who have had this for years and years, and they have been seeing other doctors. They do not have a name for it; they do not know what it is; and it bothers them a great deal. An awareness among primary care doctors, encouraging them to refer patients to us, is a great first step.1


How do you treat Hidradenitis suppurativa? Does this differ for patients with severe, recalcitrant Hidradenitis suppurativa?


In treating patients with Hidradenitis suppurativa, disease severity and how long the patient has had the disease should be considered. In the early stages, often Hidradenitis suppurativa can be managed with topical treatments and oral antibiotics, the latter of which have anti-inflammatory properties. In more moderate or even severe cases, other approaches are required, such as an injectable biologic agent, systemic retinoids, and possibly hormonal agents or surgical and procedural options, including laser therapy. Treatment is an ‘art of medicine’ approach that is decided on a case-by-case basis. Although European guidelines have been published,2 there are no American guidelines at this point, although they are being developed. Ultimately, clinicians should collaborate with their patients on a treatment plan that includes a discussion about side effects and an honest look at their expected prognosis. Although we do not have strong data that lifestyle changes necessarily improve Hidradenitis suppurativa, what we do know is that the disease is associated with smoking and obesity. Therefore, I counsel all my patients to quit smoking and maintain a healthy weight. A recent study has suggested that patients with Hidradenitis suppurativa were more likely to be of lower socioeconomic status, with diet perhaps playing a role, predisposing patients to this condition. It is very difficult to know.


What do you believe are the most challenging aspects of treating patients with Hidradenitis suppurativa?


The most challenging aspects of treating patients with Hidradenitis suppurativa are that it is chronic in nature. There is no cure; there is a dearth of available treatment choices; and there is no ‘gold standard’ therapy that, if used, is going to keep the disease under control. Treatment is patient-to-patient. Even after trying many different modalities, a patient may not do well. Some may not have the best health care or the best health insurance; therefore, coverage options might be limited. In my practice, I have noticed that lack of insurance coverage makes treatment more difficult, in part because until very recently, no medications were US Food and Drug Administration-approved for Hidradenitis suppurativa. Adalimumab is the first medication to have an FDA approval for Hidradenitis suppurativa. Some insurance companies are more likely to understand that it can be a difficult disease to treat and will cover treatment; however, others are more restrictive. This is compounded by the disease’s chronic and debilitating nature. Hidradenitis suppurativa can be so painful that people have committed suicide; they have lost their jobs; they have gone on disability. This creates a ‘perfect storm’ that can make dealing with these patients very challenging. Hidradenitis suppurativa is probably one of the worst dermatological diseases that we see, and I believe that dermatologists generally wish they could do more and better for their patients. Better recognition of this disease will help.

Background: Hidradenitis Suppurativa (HS)

Hidradenitis suppurativa (HS), also known as acne inversa, is a painful chronic inflammatory, recurrent, and debilitating disorder of the hair follicles. The condition is most prevalent between the ages of 20 and 40 years, occurs 2 to 5 times more frequently in women, and is more common in blacks. Etiology of the disease, which ranges in severity from mild to severe, is unknown, and there is no cure. Quality of life can be decreased due to pain, drainage of pus, and limitations of range of motion due to scarring.3


1) Alikhan A. Hidradenitis suppurativa. JAMA Dermatol. 2016;152(6):736. doi:10.1001/jamadermatol.2016.0185.

Gulliver W, Zouboulis CC, Prens E, et al. Evidence-based approach to the treatment of hidradenitis suppurativa/acne inversa, based on the European guidelines for hidradenitis suppurativa. Rev Endocr Metab Disord. 2016. doi:10.1007/s11154-016-9328-5.

3) Kimball AB, Okun MM, Williams DA, et al. Two phase 3 trials of adalimumab for hidradenitis suppurativa. N Engl J Med. 2016;375:422-434