Hidradenitis suppurativa is a chronic inflammatory skin disorder primarily affecting apocrine gland-bearing areas, including the axillae, groin, and buttocks. It is reported in up to 2% of Western populations and with increasing incidence in children and adults. Nearly one-third of hidradenitis suppurativa cases occur in pediatric patients and nearly half of patients endorse initial symptoms in childhood. To date, there are few clinical studies and guidelines for pediatric hidradenitis suppurativa. Here, we review the epidemiology, clinical presentation, comorbidities, and management of pediatric hidradenitis suppurativa. We discuss barriers contributing to delays in diagnosis and the significant physical and emotional impact of the disease on children and adolescents.
Hidradenitis suppurativa (HS) is a chronic, inflammatory, debilitating disease that primarily affects skin with apocrine glands. Painful nodules and abscesses occur with a predilection for skin folds and eventually form scarring. It was first described in 1833 as abscesses in the axillary, mammary, and perianal regions and was primarily treated surgically.1 In 1854, it was erroneously linked to sweat glands, which led to its name (from the Greek hydros for sweat and aden for glands).2,3 It was not until the 20th century that HS was proposed to be a primary inflammatory process of the apocrine glands.4,5 We are still elucidating the complete pathophysiology of HS.
Early identification of HS can be a challenge, as it relies on patients presenting with typical skin lesions, predilection for intertriginous sites, and recurrent flares of the disease.6–8 Waiting for the typical waxing and waning course in pediatric patients can delay diagnosis, and early disease is commonly missed or confused with infection.9 Many patients with pediatric HS (pedHS) present to emergency departments with disease flares that are managed with antibiotics or incision and drainage, and the diagnosis is not suspected.
Studies have shown that the gap between age of onset of disease and age at diagnosis of pedHS is nearly 2 years.10 Unfortunately, under-recognition leads to undertreatment, disease progression, and complications like scarring and contractures.10,11 The first 6 years of the disease are typically the most severe,6 so there is an early window of opportunity for treating aggressively to avoid permanent damage. Thus, it is important to increase awareness of HS in primary care, urgent care, and emergency department settings.
Epidemiology
The exact prevalence of HS globally has been difficult to estimate because of misdiagnosis and diagnostic delay, though recent studies show rates between 0.1% and 2%.7,12 In the United States, the overall estimated point prevalence is 0.098%, with the highest prevalence of 0.17% in those aged 30 to 39 years.13 The prevalence of pedHS is estimated at 0.03%, but the point prevalence varies with age (0.11% in 15–17 year olds, 0.03% in 10–14 year olds, and 0.002% in those younger than 9 years).14 By far the highest prevalence is observed among female adolescents aged 15 to 17 years who are African American or biracial (0.53% and 0.25%, respectively).13,14
HS was previously reported to occur most commonly between the ages of 20 and 24 years.15,16 Newer studies show a bimodal distribution, with the first peak in the late teens and the second in the mid-40s.17 Females experience earlier HS onset compared with males.17 Many adults report onset in childhood, with up to 50% of patients experiencing symptoms between 10 and 21 years of age.18
It is estimated that 7% of patients with HS develop symptoms before 13 years old and 2% before 11 years old.19 Patients with early onset HS are twice as likely to report a positive family history of the disease and are more likely to be male.20,21 No studies have associated early onset HS with more severe disease. HS is a disorder with racial and ethnic disparities with higher incidence, prevalence, and severity in Blacks and Latinos.22,23 Yet the prevalence is likely underestimated because of delays in diagnosis and limited access to specialty care,21 possibly explaining why Blacks and Latinos are found to have more severe disease at presentation.
Pathophysiology
The pathophysiology of HS is complex. Smoking, obesity, friction, and different microorganisms are just a few of the inciting events believed to exacerbate the process of follicular occlusion and dilatation, subsequent follicular rupture with inflammatory response and cytokine activation, and profibrotic imbalance leading to sinus tracts and scarring in chronic HS.24
Early HS lesions are associated with T helper type (Th) 1 and Th 17 inflammation.24 As the disease progresses, increased levels of interleukin (IL)-1, tumor necrosis factor (TNF), IL-17, S100 calcium-binding protein A9, caspase-1, and IL-10 have been reported in tissue and are supplemented by influx of neutrophils, monocytes, and mast cells.15 Dermal tunnels in chronic HS may be sources of inflammation, leading to increased expression of proinflammatory cytokines and chemokines like C-X-C motif chemokine ligand 1 (CXCL1) and CXCL8 that drive local and systemic neutrophilic infiltration.25 Additionally, imbalances in matrix metalloproteinases and tissue inhibitors of metalloproteinase increase profibrotic factors, including tissue growth factor-β 1, 2, and 3.24 This contributes to scarring and tunnel formation, hallmarks of HS.
Although HS is not a primary infection, the microbiome plays a role and superinfection is controversial. The microbiome in lesional and nonlesional skin of patients with HS differs significantly from healthy controls.26 Bacterial spread within intertriginous skin may boost immune activation.27 Distinct microbiological profiles have been identified in HS lesions depending on lesion type and severity.28 An intriguing new concept proposes that HS could be considered “autoinfectious” because of strictly cutaneous immune dysregulation led by the host microbiome.29 Further characterization of the microbiome in patients with pedHS is needed, as there may be differences from adults.
Sex hormones, particularly androgens, have been linked to the pathogenesis of HS.30 Support for hormonal involvement in disease pathophysiology includes the observations that females are predominantly affected and may experience premenstrual flares. HS also tends to improve during pregnancy, flare postpartum, and is often exacerbated by oral contraceptives with a low estrogen to progesterone ratio.31 Additionally, HS is rare before puberty or postmenopause, and can be the presenting feature of premature adrenarche.32 Children with HS may be more likely to have hormonal imbalances compared with adults.33 However, specific hormonal abnormalities or hyperandrogenism have not been demonstrated in patients with HS despite extensive study, suggesting androgen hypersensitivity may be more relevant locally at the level of the pilosebaceous unit.34
A family history of HS has been reported in up to 41% of patients.10,35 Syndromic HS has been associated with autosomal dominant mutations in the γ-secretase complex genes (NCSTN, PSEN1, PSENEN, MEFV, POFUT1, PSTPIPP1, and FGFR2), though these mutations are rare in the general HS population.29,36 These variants were initially linked to Notch signaling, which plays an important role in follicular differentiation, keratinization, occlusion, and cyst formation, but no differential expression of Notch 1 through 4 has been identified in HS affected skin.37 Genetic factors linked with sporadic cases of HS are less understood and the focus of active research.
Clinical Presentation
HS is predominantly a clinical diagnosis. Overall, its presentation in pediatric patients is similar to adult patients. Lesions include inflammatory nodules, abscesses, ulcers, comedones, sinus tracts, and variable types of scarring. Inflammatory nodules may be encapsulated or rupture with foul-smelling discharge, which may be mistaken for infection (Fig 1). Patients may have comedones, with double-headed comedones being pathognomonic for HS (Fig 2). Patients may also experience shallow, painful ulcers similar to cutaneous Crohn’s disease. In moderate to severe disease, tender, fluctuant abscesses or tunneling sinus tracts predominate. Sinus tracts consist of multiple interconnected tunnels and are almost always associated with scarring (Fig 3). Scarring includes atrophic or fish-mouth scars, hypertrophic, rope-like scars, and even contractures.
A multicenter review of 481 patients with pedHS reported that cyst or abscess (48%) and pain or tenderness (25%) were the most common signs at disease onset. Lesions at initial dermatologic assessment included cyst or abscess (49%), pustules or papules (49%), nodules (20%), double-headed comedones (23%), sinus tracts (10%), and ulcers (6%). The most commonly involved anatomic sites in pedHS are the axillae (75% to 85%), groin or inguinal folds (47% to 58%), and buttock (6% to 27%), and most patients have 1 to 2 body sites involved.10,21,38 Axillary involvement may be more likely to occur in males, whereas females have higher rates of groin involvement.39,40
Almost half (48%) of patients with pedHS already have scarring at the time of initial presentation to dermatology.10 Although this may be confounded by the observation that patients with aggressive disease are more likely to seek medical care, clinicians should be prepared or even expect to treat aggressive disease in pediatric patients. Because of their age, pediatric patients are vulnerable to undertreatment, which may lead to scarring and significant psychosocial morbidity.
Delays in diagnosing pedHS are common, ranging from 0.7 to 2 years.10,16,41,42 A comparison of claims data showed that patients with pedHS were more likely to receive diagnoses of comedones and folliculitis than adults.16 It is not clear if this reflects a difference in how early pedHS presents or true misdiagnosis. Referrals to dermatology for HS are most commonly made by pediatricians (45%). Although emergency medicine accounts for only 5% of HS referrals, up to 22% of pediatric patients report visiting the emergency department and 8% have been hospitalized.10 Targeted educational interventions may improve delays in diagnosis.
The Hurley stage scoring system is commonly used to assess HS severity (no scoring systems used in adult HS studies are validated in pedHS). Hurley stage I encompasses single or multiple abscesses without sinus tracts or scarring. Hurley stage II describes single or multiple widely separated recurrent abscesses with sinus tract formation and scarring. Hurley stage III describes diffuse involvement with interconnected tracts and abscesses across the entire area.43 Between 35% and 53% of patients with pedHS present with Hurley stage II or III disease.10,42
Hurley staging lacks quantitative and dynamic assessment over time. Other assessment tools exist, including the Sartorius scoring system, Hidradenitis Suppurativa Clinical Response, Hidradenitis Suppurativa Physician Global Assessment score, and International Hidradenitis Suppurativa Severity score system. A dynamic scoring system is important in pediatric patients, who may experience rapid progression of disease regardless of initial Hurley staging.41 Current clinical trials use Hurley stage and nodule counts for inclusion criteria, excluding many pediatric patients with moderate to severe disease.41 It will be important to consider how future trials can allow for greater enrollment of pediatric patients and better capture the dynamic course of HS.
Comorbidities
Pediatricians must be aware of the wide range of comorbidities associated with pedHS. Estimated rates of comorbidities in pedHS range from 34% to 93%.10,44,45 Comorbidity rates from several large pedHS studies are summarized in Table 1. Although no validated guidelines exist for comorbidity screening in pedHS, there are some recommendations.34,44,46 Additional guidance can be extrapolated from recently published guidelines (Table 2).34,47
Metabolic
Obesity is the strongest association with pedHS, with estimated obesity rates in patients with pedHS between 32.5% and 68.7%.10,16,38,42,44,48–51 This risk was elevated regardless of sex, age, or race. However, many studies of pedHS examined BMI according to adult measures and not percentiles, potentially confounding the true rate of obesity in this population. Despite the association, there is minimal evidence demonstrating that weight reduction improves severity of disease.
Although metabolic syndrome is not well-defined in childhood, patients with pedHS are at risk for several of the individual diagnoses that define the syndrome.52 One retrospective case-control study of 153 pedHS patients showed a 12 times higher prevalence of metabolic syndrome compared with controls.45 Hyperlipidemia is seen at higher rates in pedHS (3.2% to 16%), though lower than reported in adults.10,16,44,49 Acanthosis nigricans, often a marker of hyperinsulinemia, was found in 17 of 73 pedHS patients in 1 study.44 Studies differ as to whether patients with pedHS have increased rates of hypertension.10,16,38,44,45,49,50,53
Psychiatric
In a retrospective study of 49 280 adults and 3042 children with HS, the percentage of children with a new diagnosis of depression (14%) was lower than adults (16.3%). However, the hazard ratio when compared with population rates for age was higher for pedHS (1.87) than adult HS (1.61).54 Another study of 25 adolescent patients with HS found a positive PHQ-2 depression screen in 32% of patients, more than double the rate seen in a general adolescent population.55
Anxiety and other psychiatric disorders are also increased in pedHS. In a cross-sectional study of 87 053 155 US hospitalizations, HS accounted for 24 666 hospitalizations (899 pedHS) and was associated with a primary or secondary diagnosis of a mental health disorder (odds ratio 2.53).56 Estimated rates of these additional conditions range from 0% to 33.6% and vary by sample size, country, and study design.10,16,44,45,57 In a cohort of 153 patients with pedHS, the rate of a psychiatric comorbidity increased from 15.7% to 23.5% over 5 years, which was not seen with somatic comorbidities, highlighting the increased risk of developing psychiatric disorders after an HS diagnosis.45 Another study of 16 489 adults and children with HS also showed an increase in mood disorders after diagnosis, with Medicaid patients more likely to have psychiatric disorders than commercial or Medicare patients.53 Interestingly, in a study of 195 children from an obesity clinic, having a psychiatric comorbidity was associated with a pedHS diagnosis.58
Endocrinologic
Recent studies have shown that prepubertal onset of pedHS is more common than once thought, with prevalence estimates ranging from 7.7% to 42.4%.20,21,39,42,59 PedHS was previously thought to be associated with precocious puberty or premature adrenarche based on case reports.32,60–62 Although cases of precocious puberty and premature adrenarche are seen, they make up <5% of patients in multiple large pedHS studies.10,16,21,40,44,45
Polycystic ovarian syndrome (PCOS) is seen with increased frequency in pedHS, with reported incidences in females of 0% to 17.5%.16,21,40,42,44,45 In 1 multidisciplinary PCOS clinic, 14 (15.2%) of 92 patients had concomitant HS.63 Rates of hirsutism (6.8% to 19.7%) and irregular menses (6.5% to 25.4%) may be even more frequent.40,42,44 Baseline screening for signs of PCOS and precocious puberty are recommended, but in the absence of these no hormonal workup is indicated.44,47
Diabetes appears to be more common in pedHS (Table 1). One study of 73 patients with pedHS showed elevated rates of prediabetes (6.8%) and diabetes (type 1 and 2 combined, 2.7%), with males more likely to have prediabetes than females (21% and 3%, respectively).44 Another study of 58 patients in Asia found 17.2% with diabetes, with no difference between pediatric and adult onset HS.50 However, another study of 153 patients with pedHS showed no difference in rates of type 1 diabetes compared with controls, and no cases of type 2 diabetes.45
Skin Conditions
Acne, dissecting cellulitis, and pilonidal cysts can occur with HS in an association called the follicular occlusion tetrad.64 Acne (13.7% to 68.8%), psoriasis (2.1% to 11%), and pyoderma gangrenosum (0.2% to 0.6%) are more common in pediatric patients with HS compared with other children.10,16,38,40,42,44,45 Severe pedHS is more likely to be associated with pilonidal cysts (4.1% to 16.4%).16,40,44 Patients should be seen by a dermatologist at least annually to screen for related skin conditions.47
Down Syndrome and Other Genetic Conditions
Down syndrome, or trisomy 21, is strongly associated with HS. Anywhere from 2% to 14% of patients with pedHS have Down syndrome and these patients have an earlier age of HS onset.10,12,40,42,44,45,65–67 Patients with Down syndrome have higher overall rates of follicular occlusion disease, such as keratosis pilaris and folliculitis: 44.9% in 1 study of 243 pediatric dermatology patients with Down syndrome, and 38.9% in another study of 203 patients with Down syndrome.67,68 Regular screening for HS should be performed in all patients with Down syndrome. Partial or complete trisomy 1369–75 and keratitis-ichthyosis-deafness syndrome76,77 are also associated with pedHS.
Other Comorbidities
Patients with pedHS should be screened for inflammatory bowel disease (IBD)34,47 as IBD occurs at higher rates in patients with pedHS than the general pediatric population (0.7% to 3.3%).10,16,45,78,79 In 1 study of 109 patients with pedHS, 48.6% had gastrointestinal symptoms, and 11.3% of those were diagnosed with IBD.78 Table 1 includes additional associations, including inflammatory arthritis, anemia, atopic dermatitis, and asthma.10,16,40,42,44,45,54
Syndromic HS has also been reported in a subset of patients, typically in association with autoinflammatory disease.80,81 In these cases, HS may occur in conjunction with pyogenic or psoriatic arthritis, ankylosing spondylitis, pyoderma gangrenosum, and acne. These patients may respond to different therapies like IL-1 blockade.
Quality of Life
PedHS has a massive impact on patients’ quality of life (QoL). Concerns regarding participation in sports, ability to shave, and judgment from peers are commonly reported.44 A QoL study of 25 patients with pedHS showed an average Skindex-Teen score of 45.7 (maximum 84, range 0–84), dramatically worse in comparison with patients with psoriasis (21.1) and atopic dermatitis (29.4).55,82 The most impactful factors were appearance of affected skin and feelings of frustration about HS. QoL worsened with Hurley stage. The Family Dermatology Life Quality Index was comparable to other inflammatory skin disorders, with the most impactful factors being time spent caring for their child with HS and personal emotional distress related to their child’s condition.55
Management
There are currently no formal published clinical studies that included children or adolescents. Management of pedHS is extrapolated from adult treatment patterns, and is based on clinical presentation, lesion type and location, and severity. Overall HS treatment data are limited by small sample size, inconsistent outcome measures, and lack of validated pedHS measures. This section is guided by the 2019 North American Clinical Management Guidelines for Hidradenitis Suppurativa and recent publications and supported by pediatric case series and case reports.83 A summary of recommended treatments for pediatric patients with HS is outlined in Figure 4, with detailed information on systemic treatments in Table 3. Treatments with no other pediatric indications or established pediatric safety data are not discussed. Management of associated comorbidities is beyond the scope of this review.
Pain Management
The lesions of HS can be quite painful. Use of acetaminophen or ibuprofen should be recommended when patients are flaring, with judicious use of opiates in exceptional cases. Patients may need to be excused from physical activities during flares.
Wound Care
Abscesses and sinus tracts are often associated with serous oozing, purulent drainage, and foul odor and can severely impact QoL. Therefore, appropriate wound care education and adequate, cost-effective wound care supplies are required, noting insurance coverage can be variable. Patients may benefit from absorbent foam, hydrogel, and nonadhesive gelling fiber dressings.84
Treatments
Topical Antimicrobial Agents
Benzoyl peroxide, chlorhexidine, and zinc pyrithione washes are commonly used daily to cleanse affected areas of HS to decrease microbial colonization. Potential irritation and bleaching of fabrics are common benzoyl peroxide side effects. Clindamycin 1% solution applied once or twice daily is used first-line for mild-to-moderate HS.85 It is often combined with benzoyl peroxide wash to minimize bacterial resistance. Alternately, resorcinol 15% cream daily may be employed for its antiseptic and keratolytic properties.40,86 Irritation and burning are possible side effects. Topical dapsone gel is supported by expert opinion only as clinical data are lacking.83
Oral Antibiotics
For flares of HS, systemic antibiotic therapy is indicated. Tetracycline class antibiotics are used first-line because of their broad antibacterial coverage and anti-inflammatory action. Doxycycline is commonly used for mild-to-moderate HS over a 12-week course or as long-term maintenance if needed.83 Patients should be counseled on common side effects of photosensitivity, gastrointestinal upset, and rare hepatotoxicity. Alternately, minocycline can be employed in children 12 years and older. Potential side effects include dizziness, blue discoloration of skin or gums, and rare hepatotoxicity or drug hypersensitivity reactions.
Rifampin in combination with clindamycin systemically for 8 to 12 weeks is recommended for patients unresponsive to systemic tetracyclines.83 Fifteen percent of patients experienced nonspecific gastrointestinal upset; however, the risk of Clostridium difficile colitis should be considered. Systemic dapsone, a sulfone with anti-inflammatory properties, has been used second-line for refractory adult HS, with retrospective case series reporting ∼60% of patients achieving clinical improvement.87,88
Intravenous Antibiotics
Intralesional Corticosteroids
Triamcinolone acetonide intralesional injection has demonstrated efficacy for managing acute nodular HS lesions and can be used in willing pediatric patients.90 The addition of lidocaine 1% to injections can provide temporary anesthesia. Age-appropriate distraction techniques and topical lidocaine cream 30 minutes before injection may make the procedure more tolerable.
Biologic Therapy
A systematic review of biologic use in pedHS found that the mean duration of disease before initiating biologic treatment was 3.5 (±2.9) years.91 Most patients were Hurley stage 2. In the pooled analysis of 26 pedHS cases treated with biologics, 23.1% experienced complete resolution, 73.1% had partial response, and 3.8% had no improvement.91
Adalimumab is a TNF-α inhibitor approved for use in patients aged 12 years and older with moderate-to-severe HS. Approval in the adolescent age group was based on adult studies without additional clinical trial data.92 Dosing is based on body weight. Other TNF-α inhibitors may be employed for refractory pedHS, including infliximab, a chimeric monoclonal antibody infusion. However, data on use of etanercept in HS are mostly nonsupportive.93–95
Side effects of TNF-α inhibitors include increased risk of opportunistic infections and reactivation of tuberculosis and hepatitis B.96 There is a small increased risk of malignancy, particularly lymphomas, made worse by concomitant use of immunosuppressants. Patients on TNF-α inhibitors (especially adalimumab) are at risk for autoimmunity with antidrug antibody formation and lupus-like reactions. Paradoxical exacerbation of HS has been reported with TNF-α inhibitor use.97
IL-17a inhibitors (secukinumab, ixekizumab), approved for pediatric psoriasis, have been effective in limited adult HS case series.98,99 A systematic review of biologic use in pedHS reported limited cases of ustekinumab (IL-12/23 inhibitor) and anakinra (IL-1 inhibitor) treatment.91
All patients should be tested for tuberculosis and hepatitis B before starting a biologic agent. All age-appropriate vaccines should be given 1 month before starting a biologic, and live vaccines should not be given to children on biologic therapy.100
Hormonal Therapies
Hormonal therapies are used with increasing frequency in adolescents with HS; however, data are limited.101 Combined oral contraceptive pills are employed as adjunctive therapy in female patients with HS. Progestins with greater antiandrogenic activity (ie, norgestimate, drospirenone) are recommended. Data suggest that patients with perimenstrual flares of HS and those on concomitant treatments respond better than patients without cyclical flares or on combined oral contraceptive monotherapy.102 Before starting a combined oral contraceptive, patients should be appropriately screened for blood clot and stroke risk, hypertension, migraine with aura, and liver tumor. Note that rifampin will decrease the efficacy of combined oral contraceptives.103
Spironolactone, an antiandrogen and potassium-sparing diuretic, may be used alone or in combination with combined oral contraceptives in postmenarchal females with HS. Side effects include menstrual irregularity and breast tenderness. Hyperkalemia may result, primarily in those with renal dysfunction; however, serum potassium monitoring is not required for otherwise healthy patients.104
Finasteride, a systemic 5α-reductase inhibitor, has been used in adults and children with HS unresponsive to or intolerant of other antiandrogens.105 Potential side effects include headache, dizziness, nausea, breast tenderness, gynecomastia, and menstrual irregularity. Metformin decreases hepatic glucose production and is an antiandrogen. It is an adjunctive therapy predominantly used in patients with HS and associated hyperinsulinemia.106 Potential side effects include gastrointestinal upset, decreased absorption of vitamin B12, and lactic acidosis.
Retinoids
Isotretinoin has demonstrated variable efficacy in limited retrospective and prospective studies for HS.107–109 Typical dosing is 0.5 to 1.0 mg/kg per day. Because of its teratogenicity, isotretinoin is subject to a mandatory US Food and Drug Administration risk management program (iPLEDGE) for all patients in the United States. Acitretin, also a teratogen, should be used with extreme caution in patients of childbearing potential because of its prolonged half-life. Other retinoid side effects include cheilitis, hyperlipidemia, transaminitis, and rare pancreatitis. Because of pseudotumor cerebri risk, isotretinoin should not be used with systemic tetracyclines.
Systemic Immunomodulators
Systemic corticosteroids, 0.5 to 1.0 mg/kg per day, are used for 7 to 10 days to control flares of HS and serve as a bridge to other systemic therapy.83
Combination therapy utilizing cyclosporine with adalimumab has been reported in adult patients with severe HS.110 Side effects of cyclosporine include immunosuppression, kidney damage, hypertension, and decreased cell counts; therefore, close clinical and laboratory monitoring is required. Based on adult case series, colchicine 0.5 mg twice daily is used as adjunctive therapy most commonly with systemic tetracyclines.111 Methotrexate and azathioprine are not recommended for HS.83
Surgical Management
When the recurrent lesions of HS form scars and sinus tracts, surgical intervention may be required. Incision and drainage should only be performed for painful, acute disease with grossly purulent abscesses. It is not recommended as definitive therapy because of high recurrence rates. Other surgical techniques, like punch debridement (for small nodules) or a tissue sparing deroofing procedure (for epithelialized tracts), can be performed in both the acute and chronic setting with careful attention to pain control.112 Larger areas of severe, chronic disease may require wide local excision with the potential need for skin grafts or flaps. Depending on the patient’s age and extent of the surgical procedure chosen, these may be done under local or general anesthesia by an experienced pediatric, plastic, or dermatologic surgeon.
Laser hair removal utilizing long-pulsed neodymium-doped yttrium aluminum garnet (Nd:YAG) or alexandrite lasers may be useful in patients with mild-to-moderate HS. Multiple treatments are required; they are moderately painful and may not be covered by insurance, so appropriate patient selection is needed. In a prospective study of 20 adults with mild-to-moderate HS treated with alexandrite laser compared with 20 untreated matched control patients, treated patients reported decreased pain, improved QoL metrics, and longer flare-free periods at 15 and 30 weeks.113
Botulinum toxin A injections to reduce sweating in the axillae and groin have been reported to be beneficial in small case series and case reports in both pediatric and adult patients with HS, particularly those with associated hyperhidrosis.114
Patient Education
HS is a chronic condition with long-term health implications. Educating patients and parents about the disease is vital to empowering them and increasing adherence. Table 5 lists resources for families.
Conclusions
PedHS is an underrecognized inflammatory disease with tremendous impact on QoL during an important time in development. With a high burden of comorbidities and variable treatment options, multimodal management with medications, surgery, and multiple subspecialists is often necessary for more advanced disease. Early recognition and intervention allow clinicians to act during a window of opportunity where treatments are more effective.
Dr Cotton conceptualized and designed the study, performed the initial literature review, and drafted the initial manuscript; Drs Lara-Corrales, Chen, and Hussain drafted portions of the initial manuscript; Dr Zaenglein conceptualized and designed the study, and drafted portions of the initial manuscript; and all authors critically reviewed and revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.
FUNDING: This project was supported by the Pediatric Dermatology Research Alliance (PeDRA).
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.