Pediatric HS care shows delayed treatment escalation and heavy reliance on antibiotics.

Hidradenitis suppurativa (HS) in pediatric patients remains associated with substantial morbidity, and new real-world evidence suggests that treatment patterns may contribute to ongoing disease burden. A retrospective cohort study published in Pediatric Dermatology evaluated treatment initiation, first-line therapy, and time to treatment switching among children with HS across demographic groups.^1,2

Using a national electronic health record database spanning 2005 to 2025, investigators analyzed 6659 patients younger than 18 years with a diagnosis of HS. The mean age at diagnosis was 12.8 years, and most patients were female (74.9%).

Treatment initiation occurs relatively quickly, but varies by race

Across the cohort, the mean time to treatment initiation following HS diagnosis was approximately 15 days. However, differences emerged across racial groups. Non-White children initiated treatment significantly earlier than White children, with a mean time of 1.0 day vs 16.8 days, respectively.

No significant differences in time to treatment initiation were observed between sexes or between Hispanic/Latino and non-Hispanic/Latino patients.

These findings align with prior observations that HS may present with greater severity among non-White pediatric patients, potentially prompting earlier clinical intervention. The authors noted that “increased emergency department utilization among non-White children with HS may contribute to earlier clinician recognition and initiation of therapy.”

Initial treatment patterns are dominated by antibiotics

The study found that initial treatment strategies were largely consistent across demographic groups and were dominated by antibiotic-based regimens. The most common first prescribed therapy was a combination of systemic antibiotics and topical treatments, used in 56.7% of patients.

Overall, topical therapies (26.0%) and systemic antibiotics (23.6%) were the most frequently prescribed treatment categories. In contrast, biologic therapies were used in only 3.2% of pediatric patients, although this increased to 6.1% in more recent years following regulatory approvals.

The predominance of antibiotic-based regimens may reflect disease severity at presentation. The authors wrote, “This suggests that patients may present at least at a moderate stage to warrant systemic antibiotic use.”

Prolonged time to treatment escalation

A key finding of the analysis was the extended duration of initial therapy before switching to another treatment. The mean time on first-line therapy was approximately 386 days.

The authors emphasized that “most children remained on their initial HS treatment for a mean duration of approximately a year before switching therapies.” While prolonged treatment may reflect adequate disease control in some cases, it may also indicate delays in treatment escalation for patients with persistent or worsening disease.

Differences in treatment duration were also observed across demographic groups. Boys remained on initial therapy longer than girls, and non-White children remained on therapy longer than White children. Hispanic/Latino patients also had longer durations on first-line treatment compared with non-Hispanic/Latino patients.

Sex-based differences in treatment utilization

The study identified notable differences in treatment utilization by sex. Girls were more likely than boys to receive most therapies, including systemic antibiotics, topical treatments, biologics, and hormonal therapies.

Hormonal therapies were used more frequently in girls, which the authors attributed to the antiandrogenic mechanisms of commonly prescribed agents such as oral contraceptives and spironolactone.

Implications for clinical practice

The findings highlight several potential gaps in pediatric HS management, including delayed escalation of therapy and reliance on antibiotic-based regimens. The authors noted, “Given the progressive nature of HS in many patients and evidence that early, effective intervention may improve outcomes, this prolonged time to treatment modification highlights a potential gap in timely disease escalation.”

Barriers contributing to these patterns may include limited access to pediatric dermatology care, variability in clinician familiarity with HS management, and delays in diagnosis. Nearly one-third of children in the United States live more than an hour from a pediatric dermatologist, which may affect timely treatment adjustments.

Conclusion

This large real-world analysis demonstrates that pediatric HS care is characterized by early treatment initiation but delayed escalation, with antibiotic-dominant first-line therapy and demographic differences in treatment timing. These findings underscore the need for earlier recognition, more timely reassessment of treatment response, and improved access to specialized care to optimize outcomes in pediatric HS.

References

1. Aflatooni S, Ure A, Smart K, et al. Treatment patterns in pediatric hidradenitis suppurativa: time to treatment initiation, initial treatment, and time to switching. Pediatr Dermatol. Published online April 14, 2026. doi:10.1111/pde.70214

2. Numani A, Ziebart R, Todd A, Alavi A, Mohandesi NA, Davis DMR. Characterizing disease severity, comorbidities, and treatment plans in pediatric hidradenitis suppurativa patients with and without obesity: a cohort and cross-sectional analysis. Pediatr Dermatol. 2025;42(4):773-778. doi:10.1111/pde.15983