If you’ve been managing hidradenitis suppurativa for any length of time, you know the frustration: the list of “proven” treatments has historically been short, and a lot of us have spent years cycling through antibiotics, topicals, and trial-and-error before landing on something that actually works.
The good news is that the treatment landscape is expanding — fast. Here’s a breakdown of where things stand right now, across every major category of HS treatment.
Biologics: The Current Gold Standard
Biologics remain the most well-studied, long-term treatment option for moderate-to-severe HS. There are currently three FDA-approved options:
- Adalimumab (Humira) — a TNF-alpha inhibitor, and the first biologic approved for HS, back in 2015
- Secukinumab (Cosentyx) — an IL-17A inhibitor, approved in 2023
- Bimekizumab (Bimzelx) — an IL-17A/F inhibitor, the newest addition to the lineup
These medications work by targeting specific inflammatory messengers in the immune system — the same pathways driving the nodules, tunnels, and flares that come with HS. Unlike antibiotics (more on that below), biologics are designed and clinically studied for long-term, sustained use. That’s an important distinction when you’re thinking about a treatment plan that needs to last years, not months.
Coming Soon: JAK Inhibitors
The next wave of HS treatment is oral JAK inhibitors — pills rather than injections — which work by blocking the JAK-STAT signaling pathway that fuels HS inflammation from inside the cell, rather than targeting inflammatory messengers from outside it.
Two are worth watching:
- Povorcitinib is the furthest along, currently in Phase 3 trials (STOP-HS1 and STOP-HS2). New 54-week data was presented this year, and it’s considered the closest JAK inhibitor to FDA approval for HS.
- Upadacitinib (Rinvoq) is already approved for other conditions like rheumatoid arthritis and eczema, and is currently being studied specifically for HS.
If and when these get approved, they’ll give patients — and prescribers — more tools to work with, especially for people who haven’t responded to biologics or can’t access them.
Trial phases and approval timelines shift, so if this is relevant to your care, it’s worth asking your dermatologist what’s current.
Metabolic Support: Metformin, Spironolactone, and GLP-1s
One of the things I talk about often is that HS isn’t just a skin disease — it’s deeply intertwined with metabolic and hormonal inflammation. That’s why some dermatologists incorporate these medications as adjunct therapy, even though none of them were originally developed for HS:
- Metformin improves insulin sensitivity, which can help lower the inflammatory load that drives flares.
- Spironolactone is an anti-androgen, often used for hormonally-driven HS — particularly flares tied to the jawline or menstrual cycle.
- GLP-1 medications are the newest addition to this conversation. Emerging research is looking at their anti-inflammatory effects in HS specifically, not just their impact on weight.
None of these replace targeted HS treatment, but they reflect something important: treating HS well often means treating the metabolic and hormonal terrain it grows in, not just the skin itself.
Antibiotics: Not What You Think
Doxycycline and other antibiotics are commonly prescribed for HS, but there’s a nuance that gets missed a lot: they’re usually prescribed at a low dose specifically for their anti-inflammatory effect — not to treat an active infection. HS isn’t primarily a bacterial disease, even though flares can look and feel that way.
Here’s my honest take on this, as someone who has spent years in this space: antibiotics feel more benign than biologics because they’re familiar, cheap, and easy to prescribe. But long-term antibiotic use comes with real, serious downsides — disruption to the gut microbiome, antibiotic resistance, and knock-on effects to overall health that we’re still learning more about.
Biologics, by contrast, are literally designed and studied for long-term, sustained use. So if you find yourself on antibiotics for HS for years at a time with no clear exit plan, that’s worth bringing up directly with your doctor. Ask what the long-term strategy actually is — and whether a biologic might be the more sustainable path forward for your specific case.
This isn’t medical advice, and it’s not a blanket statement that antibiotics are wrong for everyone. It’s a pattern I think is worth questioning with your care team, especially if “temporary” antibiotic use has quietly stretched into years.
The Common Thread: Lifestyle Still Matters
No matter which treatment path you’re on — biologic, JAK inhibitor, metabolic support, or antibiotics — an anti-inflammatory diet and stress management still have a place in your care plan. Medication addresses the immune and inflammatory cascade directly. Lifestyle supports the terrain that inflammation is happening in. Both matter, and neither replaces the other.
This post is intended for patient education and reflects general information about current and emerging HS treatments. It is not medical advice. Always talk to your dermatologist or care team before starting, stopping, or changing any treatment.
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