Is hidradenitis suppurativa (HS) considered an immunocompromised condition?

Is Hidradenitis Suppurativa Considered Immunocompromised?

No, hidradenitis suppurativa (HS) itself is not an immunocompromised condition—it is a chronic inflammatory disease characterized by aberrant immune activation, not immune deficiency. However, patients with HS may require immunosuppressive treatments that can create an iatrogenic immunocompromised state.

Understanding HS Pathophysiology

HS is fundamentally a disease of excessive inflammation, not immune deficiency:

• The pathogenesis involves follicular occlusion followed by follicular rupture, triggering massive immune cell infiltration with elevated proinflammatory cytokines (IL-1β, TNF-α, IL-17, and IFN-γ) 1
• The disease demonstrates aberrant immunity with significant inflammatory responses involving innate and adaptive immune pathways, not immunosuppression 1, 2
• Histopathological studies confirm HS as primarily a disease of follicular occlusion with subsequent inflammatory cascade, involving neutrophils, macrophages, plasma cells, and activated Th1/Th17 cells 1, 2

When HS Patients Become Immunocompromised

Patients with HS are NOT inherently immunocompromised, but treatment can create this state:

• When patients receive immunosuppressive medications (corticosteroids, methotrexate) or biologics (anti-TNF agents, IL-17 inhibitors, IL-12/23 inhibitors) for HS management, they become iatrogenically immunocompromised 1
• The 2025 North American guidelines specifically address HS management in special populations including those with tuberculosis, hepatitis B/C, HIV, and malignancy—contexts where immunosuppression matters 1

Clinical Implications for Infection Screening

Because HS treatments often involve immunosuppression, specific screening protocols are mandatory:

• For biologics: Screen for tuberculosis (TB) with TST and/or IGRA prior to initiation; in endemic regions with high BCG vaccination rates, IGRA improves sensitivity and specificity 1
• For glucocorticoids: Annual TB screening is required if the dose exceeds 15 mg prednisone equivalent daily for at least 4 weeks 1
• For latent TB: Start prophylactic antibiotics at least 1 month before biologic initiation in patients not at high risk for active TB 1
• Consider screening for hepatitis B and C before initiating immunosuppressive therapy 1

Important Distinction from True Immunodeficiency

HS patients without immunosuppressive treatment do not have the infection risks of truly immunocompromised patients:

• The disease involves hyperactive, not deficient, immune responses 2
• Bacterial colonization in HS lesions represents secondary infection of inflamed tissue, not primary immunodeficiency 1
• The benefit of antibiotics in HS likely derives from anti-inflammatory properties rather than purely bactericidal effects 1

Practical Management Considerations

When considering immunosuppressive medications for HS, consult with specialists and account for:

• Activity of HS disease
• Patient's age
• Time since completion of any cancer treatment (if applicable)
• Individual carcinogenic effects of specific immunosuppressants
• Use shared decision-making to respect patient preferences 1

Common pitfall: Do not treat HS patients as immunocompromised unless they are actively receiving immunosuppressive therapy. The disease itself represents immune dysregulation with excessive inflammation, not immune deficiency 1, 2.