Simple screening questions may help pediatricians identify hidradenitis suppurativa earlier

Hidradenitis suppurativa (HS) frequently goes unrecognized in pediatric practice, in part because many children and adolescents are reluctant to discuss symptoms involving sensitive areas of the body. According to Colleen Cotton, MD, pediatricians can play an important role in improving recognition by incorporating simple screening questions into routine care, particularly for patients at higher risk of the disease.¹

In a recent interview, Cotton, associate professor of dermatology and pediatrics at George Washington University School of Medicine and Health Sciences and director of the multidisciplinary pediatric HS clinic at Children's National Hospital, discussed practical strategies for identifying HS earlier and reducing delays in diagnosis.

Patients may not volunteer symptoms

Cotton noted that HS symptoms are often disclosed only at the end of an appointment, if they are mentioned at all.

"So, I think asking about it first of all, because this, you know, I see a ton of HS, and this still ends up being like a hand on the door kind of question, where they come in for something else, and they're like, also she gets some boils in her groin, or she gets ingrown hairs in her groin," Cotton said.

She explained that embarrassment frequently prevents patients from bringing symptoms to a clinician's attention.

"The kids are always embarrassed, and they don't really want to talk about it, and so they may not bring it up until it is really bad," Cotton said.

Because of this, Cotton encouraged clinicians to consider examining common HS sites, including the underarms, during routine adolescent visits when appropriate and acceptable to the patient.

Certain patients may be at higher risk

Cotton also highlighted several comorbid conditions associated with increased HS risk.

"If there are patients who have some of these comorbidities that we know are higher risk, patients with, for example, Crohn's disease, patients with obesity, polycystic ovarian syndrome, severe cystic acne, asking them if they have anything in their underarms, in their groin, if they have any painful spots that are coming and going," she said.

HS commonly affects skin folds, including the underarms and groin, but lesions may also occur on the chest and buttocks. According to Cotton, patients with polycystic ovarian syndrome may dismiss lesions as ingrown hairs, while those with severe acne may assume symptoms are simply another manifestation of acne.

Recognizing HS in these populations is important because treatments used for associated conditions may not adequately address underlying HS. Early identification may facilitate timely referral and more targeted management.

A simple screening question may help

Cotton emphasized that screening for HS can be straightforward and does not require lengthy questionnaires or specialized tools.

"It's super easy to screen," she said.

She recommended asking patients a single question:

"You can just ask them, in the last year, have you had two or more outbreaks of painful bumps or boils in any skin fold areas?" Cotton said. "That's it. Period. That's all you have to do."

According to Cotton, this screening approach has demonstrated strong performance in adults.

"In adults, that question is 96% sensitive, so you're going to catch almost all patients with HS, and it's also quite specific," she said.

Screening may help reduce diagnostic delays

For pediatricians, routinely asking about recurrent painful lesions in skin folds may help uncover symptoms that otherwise go unreported. Cotton suggested that incorporating the question into visits for patients with known risk factors could improve recognition and facilitate earlier referral to dermatology.

"Really easy screening question, especially to throw in for your patients who are higher risk," Cotton said. "That would be something to help recognize this early."

As awareness of pediatric HS continues to grow, simple screening strategies may help clinicians identify affected patients before significant disease progression occurs.

Editor’s note: This article is part 5 of a 5-part video series highlighting key clinical considerations in pediatric hidradenitis suppurativa (HS). During HS Awareness Week. Visit the website to view previous episodes in the series.

Disclosure: Cotton reports no relevant disclosures

Reference

1. Sabat R, Alavi A, Wolk K, et al. Hidradenitis suppurativa. Lancet. 2025;405(10476):420-438. doi:10.1016/S0140-6736(24)02475-9