How can we improve patient care in hidradenitis suppurativa?

Hidradenitis suppurativa (HS) is a chronic, autoinflammatory disease characterized by painful, deep-seated nodules, abscesses and malodorous draining tunnels in flexural areas. It is a debilitating disease, imposing a major physical, social and emotional burden on patients.1-3 HS also has considerable impact on treating dermatologists due to diagnostic delays and the complexity of long-term management. In their prospective, cross-sectional, multicentre survey conducted across 20 dermatology centres in Germany (May 2023–July 2024), Wolk et al. quantify what many dermatologists and patients experience in practice: HS care is perceived as substantially less satisfactory than psoriasis care.1 On a 0–10 scale, patients with HS rated overall satisfaction significantly lower than patients with psoriasis (mean 6.7 ± 2.70 vs. 8.6 ± 2.03, p = 0.000), and dermatologists mirrored this gap (mean 5.1 ± 1.87 vs. 7.5 ± 1.80, p = 0.000).1 These findings align with real-world data showing that 34% of HS patients continue to experience moderate-to-severe disease and significant quality-of-life impairment despite being actively treated by a dermatologist.3 Patient satisfaction is a multicomponent indicator of healthcare quality, especially in chronic, burdensome diseases such as HS.4 It encompasses access to care, the quality of the patient–physician relationship, coordination and continuity across providers, treatment efficacy and tolerance burden.4 In the present study, satisfaction appears highest among patients treated in university hospitals.1 This is not unexpected, as tertiary centres are more likely to host dedicated multidisciplinary units enabling timely access to complex surgery and participation in clinical trials. The value of such integrated care models has been previously reported.5 The most pronounced disparity—reported by both patients and physicians—concerns satisfaction with available systemic therapies. Only 10.3% of HS patients were highly satisfied with systemic therapies compared with 66.3% of psoriasis patients (p < 0.001).1, 2 Likewise, only 2.5% of dermatologists reported high satisfaction with HS therapies versus 69.4% for psoriasis therapies (p < 0.001).1, 2 This is to be expected, as psoriasis is a model, chronic, inflammatory disease with a broad systemic armamentarium and a well-structured, treat-to-target approach, enabling many patients to achieve near-complete clearance. In contrast, adalimumab, secukinumab and bimekizumab remain the only approved systemics for moderate-to-severe HS. Although effective for many patients, their efficacy outcomes remain modest (50% reduction in inflammatory lesions), and opportunities for timely therapeutic escalation are limited, particularly when inclusion in clinical trials is not available. Notably, secukinumab and bimekizumab received EMA approval for HS during the survey period (June 2023 and April 2024), so only a small proportion of patients had received these agents at the time. In all, from both patients' and physicians' perspectives, the perceived limited efficacy of available systemic options appears central to the overall care experience. Prior work on HS patients' satisfaction has focused mainly on treatment, yet points to the same direction. Midgette et al. reported higher treatment satisfaction when HS care was provided by a dermatologist and involved a biologic medication, whereas active tobacco smoking, multiple comorbidities and depression were associated with lower satisfaction.3 A limitation of the present study is that, although intuitive and clinically relatable, the 0–10 satisfaction scale can only partially capture the different interconnected determinants of patient satisfaction.1, 4 The priority now is to translate this emerging patient–physician consensus into structured care models with accessible, multidisciplinary, expert units for patients with difficult-to-treat HS. Furthermore, more effective, treat-to-target strategies with explicit criteria for timely escalation are required for HS care to approach the psoriasis paradigm. Hopefully, with numerous investigational drugs in the pipeline, the therapeutic landscape for moderate-to-severe HS is expected to evolve, with the potential to transform long-term outcomes in the near future. Maria Polina Konstantinou has received travel support from Sanofi and Lilly and honoraria from Boeringer Ingelheim. Sabine Kruger-Krasagakis has received honoraria for lectures, presentations or educational events from Galderma and UCB; support for attending meetings and/or travel from AbbVie, Eli Lilly, Galderma, Genesis, LEO Pharma, Pfizer and UCB; and has participated on the advisory board for Galderma, UCB, Janssen and AbbVie. Konstantinos Krasagakis has received grants from Eli Lilly and Leo Pharma, travel support from AbbVie, Eli Lilly, Janssen, LEO Pharma, UCB, honoraria from UCB, and Eli Lilly, and has participated on Advisory Boards for Eli Lilly, Boehringer Ingelheim, Sanofi, UCB. Data sharing is not applicable to this article as no new data were created or analyzed in this study.