Optimizing therapy in hidradenitis suppurativa: Combination, sequencing and treat-to-target

Hidradenitis suppurativa (HS) is a chronic, recurrent and progressively destructive inflammatory disease associated with substantial physical, psychological and social burden. The therapeutic landscape of HS has rapidly evolved with the introduction of biologics targeting TNF-α and IL-17 pathways, increasing use of metabolic and hormonal interventions and growing integration of surgery with systemic therapy. However, despite expanding treatment options, many patients continue to experience incomplete disease control, progressive tunnel formation and cumulative disability. This narrative review discusses optimization of currently available medical therapies in HS, with a particular focus on treatment sequencing, rational combination strategies and treat-to-target principles. Rather than viewing therapies as isolated interventions, modern HS management increasingly requires dynamic, phenotype-driven integration of biologics, antibiotics, hormonal and metabolic therapies and surgery according to inflammatory burden, structural disease and comorbidities. We discuss the evolving role of systemic antibiotics as time-limited induction therapies rather than chronic suppressive treatment, practical approaches to biologic sequencing and dose optimization and the emerging rationale for combining biologic therapy with metabolic or procedural interventions. The review also highlights the importance of early inflammatory control within a potential therapeutic 'window of opportunity' to prevent irreversible tunnel formation and long-term structural damage. In parallel, patient-reported outcomes, pain control and quality of life are increasingly recognized as essential therapeutic targets alongside objective inflammatory measures such as HiSCR and IHS4. Ultimately, optimization of HS therapy should aim not merely at short-term reduction of inflammatory lesions but at long-term modification of disease trajectory, prevention of irreversible disability and restoration of quality of life through individualized, multidimensional and strategically integrated care.