What are the key management strategies for pediatric patients with Hidradenitis Suppurativa (HS)?

High-Yield Clinical Pearls for Pediatric Hidradenitis Suppurativa

Age-Specific Recognition and Diagnostic Considerations

Pediatric HS typically presents at mean age 12.5 years, with diagnosis delayed until 14.4 years, and 48% of patients already have scarring at initial dermatologic assessment 1, 2. This diagnostic delay is critical—early recognition prevents irreversible complications.

• First presenting signs differ from adults: cyst/abscess (48%), pain/tenderness (25%), or papules/pustules (24%) rather than classic double-ended comedones 2
• Family history is present in 41% of pediatric cases—always ask about parental HS 2
• Female predominance is striking: 80% of pediatric HS patients are girls, with African American/Black children disproportionately affected (93.6% in ED studies) 2, 3
• Hurley staging at presentation: 47% stage I, 45% stage II, 8% stage III—nearly half present with moderate disease requiring systemic therapy 2

Critical Comorbidity Screening

Screen every pediatric HS patient for metabolic syndrome, hormonal imbalances, and psychological comorbidities at diagnosis 1, 4.

• Obesity affects 65% of pediatric HS patients—weight management is essential adjunctive therapy 2
• Acne vulgaris co-occurs in 29%—isotretinoin should only be used when moderate-to-severe acne is present, not for HS alone 1, 2
• Depression and anxiety are common—psychological support is integral to management 1, 4
• Hormonal imbalances are more frequent in children than adults—hormonal investigations are integral to pediatric disease management 4

Age-Appropriate Medical Management Algorithm

Mild Disease (Hurley Stage I)

Start with topical clindamycin 1% twice daily for 12 weeks, combined with antiseptic washes to reduce bacterial resistance 1.

• Add benzoyl peroxide or chlorhexidine wash to prevent Staphylococcus aureus resistance with topical clindamycin 1
• Topical retinoids or resorcinol 15% can be used in select cases, though evidence is very low quality 1
• Intralesional triamcinolone 10 mg/mL for acute localized flares, with appropriate pain management and distraction techniques based on patient age and procedural tolerance 1

Moderate Disease (Hurley Stage II)

First-line systemic therapy is oral doxycycline 100 mg once or twice daily for patients ≥8 years old 1.

• Doxycycline is recommended (strong evidence) for ages ≥8 years, with treatment duration up to 4 months (12-16 weeks) 1
• Minocycline is second-line for doxycycline intolerance in patients ≥8 years 1
• For patients <8 years or inadequate doxycycline response: escalate to clindamycin 300 mg + rifampin 300-600 mg twice daily for 10-12 weeks 1

Severe/Refractory Disease (Hurley Stage III or Failed Antibiotics)

Adalimumab is the first-line biologic with FDA approval for ages ≥12 years (strong recommendation) and suggested for ages 2-11 years 1, 5.

• Dosing for ages ≥12 years: 160 mg week 0,80 mg week 2, then 40 mg weekly starting week 4 1, 5
• Alternative biologics for ages ≥6 years: infliximab, secukinumab, or ustekinumab (all conditional recommendations with moderate quality evidence) 1
• Prednisone for acute widespread flares only—not for chronic management 1
• Cyclosporine should be limited to select treatment-refractory cases 1

Hormonal Therapy Considerations

Anti-androgens are appropriate for adolescent females and select male patients 1.

• Spironolactone is suggested for adolescent females requiring anti-androgens 1
• Combined oral contraceptives are suggested for adolescent females 1
• Finasteride in select cases, particularly for male patients 1
• Metformin especially when insulin resistance is present 1

Critical Management Pitfalls

Avoid I&D as primary treatment—it's performed in 29.3% of pediatric HS ED encounters but contradicts guideline recommendations 3.

• I&D does not address underlying inflammation and may worsen scarring 3
• Oral clindamycin monotherapy is insufficient—62.1% of ED encounters prescribe it alone, but combination with rifampin is superior for moderate disease 3
• Isotretinoin should NOT be used for HS alone—only when concomitant moderate-to-severe acne is present 1
• Do not delay dermatology referral—only 3.4% of pediatric HS ED encounters involve dermatology consultation, yet dermatology management significantly increases use of standard-of-care therapies and biologics 6, 3

Surgical Considerations

Surgery is often necessary for lasting cure in advanced disease, but timing and technique matter 1.

• Deroofing for recurrent nodules and tunnels in localized disease 1
• Radical excision for extensive disease with sinus tracts and scarring 1
• Patients managed by dermatology are less likely to undergo surgical excision (13.3% vs 25.5%)—suggesting medical optimization may reduce surgical need 6

Psychosocial Impact and Quality of Life

HS significantly impacts self-esteem and quality of life—psychological support is not optional 4.

• 79% of pediatric patients develop complications, with 80% experiencing scars or contractures 2
• Pain management with NSAIDs for symptomatic relief 1
• Appropriate wound dressings for draining lesions 1
• Early treatment minimizes effects on life course—delayed diagnosis until age 14.4 years when disease onset is 12.5 years represents a critical 2-year window for intervention 2

Referral and Access Patterns

76.1% of pediatric HS patients are eventually seen by dermatology, but 79.1% require referral—indicating primary care recognition gaps 6.

• Dermatology-managed patients are significantly more likely to receive standard-of-care therapies (p<0.001) 6
• 19.7% of dermatology-managed patients receive biologics vs 0% of non-dermatology-managed patients 6
• Only 22.4% of HS ED encounters result in outpatient dermatology referrals—this should approach 100% for moderate-to-severe cases 3