Management of Hidradenitis Suppurativa in Special Populations: A Narrative Review

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease that can be treated with a variety of medical and surgical therapies. However, these therapies carry inherent risks that might be heightened in medically complex patients. This narrative review examines literature for the nuances of standard HS management in immunosuppressed individuals, patients with cancer, and those with gastrointestinal or cardiovascular comorbidities, Down syndrome, and PASH syndrome, a rare condition that is characterized by the presence of pyoderma gangrenosum (PG), acne, and HS. The treatment of HS often requires systemic immunomodulators, and their use necessitates a careful risk-benefit analysis to balance disease control and infection risk in patients who are immunosuppressed. Owing to chronic inflammation, HS is associated with an increased risk of malignancies such as cutaneous squamous cell carcinoma. Vigilant screening and histopathologic evaluation of chronic HS lesions are required for chronic lesions and patients with concurrent cancer. There is a high prevalence of inflammatory bowel disease (IBD) in patients with HS, and this can present unique challenges in management. For example, some biologic therapies commonly used for HS can exacerbate IBD symptoms. Cardiovascular disease is a common comorbidity in HS and demands a multidisciplinary approach to risk assessment and treatment, particularly given the systemic inflammatory burden of HS. Patients with Down syndrome are disproportionately affected by HS and often receive suboptimal treatment, underscoring the need for improved screening and access to therapies. PASH and other related syndromes are rare variants of HS and can be a challenge to manage owing to their unpredictable response to tumor necrosis factor-alpha (TNF-α) and interleukin-1 (IL-1) inhibitors. Across these unique populations, surgical intervention continues to be a viable option in refractory cases, even with the risk of impaired wound healing in patients who are immunosuppressed and have cancer. Ultimately, a comprehensive, multidisciplinary approach is essential to optimize HS management in these special populations, integrating surgical and systemic therapies while mitigating associated risks.