Colleen Cotton, MD, on the importance of early recognition in hidradenitis suppurativa

Hidradenitis suppurativa (HS) is often viewed as an adult condition, but many patients develop symptoms during adolescence, making early recognition critical for pediatric care.

In a recent interview, Colleen Cotton, MD, 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 how HS presents in children and adolescents and why prompt diagnosis is important.

HS often begins during adolescence

Although HS is uncommon across the pediatric population as a whole, Cotton noted that incidence rates among adolescents are similar to those seen in adults, particularly among patients with skin of color and those from lower socioeconomic backgrounds.

"So, to start, while overall across all the ages that we consider to be pediatrics, HS is pretty rare when you actually look at the epidemiology of the disease in adolescence, particularly adolescents with skin of color or of lower socioeconomic backgrounds, that incidence is somewhere between half to 1% which is on par with the amount and frequency of the disease that we see in adults," Cotton said.

Adolescence is also the period when symptoms frequently begin. According to Cotton, approximately half of adults with HS report symptom onset before age 20.¹

"One study that looked and said about half of patients, adult patients with HS, first had their symptoms when they were under the age of 20 and started in adolescence," Cotton said. "It's really the time that this starts for a good chunk of people who end up continuing on with this disease into adulthood."¹

Diagnostic delays can hinder early treatment

Despite this, diagnosis is often delayed. Cotton said pediatric patients experience an average 2-year gap between symptom onset and diagnosis, while delays in adults have been estimated at 7 to 10 years.

"There is, on average, about a 2-year delay between the onset of symptoms and when people receive a diagnosis in pediatrics, but there are likely others that have an even longer delay," she said.¹

Pediatric disease may present differently than adult HS

One reason for delayed recognition is that pediatric HS may not follow the classic recurrence patterns commonly used to identify the disease in adults. Adult diagnostic criteria often emphasize multiple flares within a 6-month period, but children may experience less frequent recurrences early in the disease course.²

"In adults, we think about having had at least two or more flares within a 6-month period," Cotton said. "That doesn't always apply to kids."

Expanding the timeframe to 1 year may help identify most pediatric patients with HS, she noted.

Early intervention may help prevent scarring and disease progression

Cotton emphasized that early diagnosis creates an opportunity to intervene before irreversible disease progression occurs.

"It is very important to recognize these kids as soon as possible, because we know there is this window of opportunity for us to intervene," she said.

Repeated inflammation can lead to scarring and the formation of tunnels, changes that are associated with more difficult-to-treat disease.

"The more scarring and the more tunneling happens in this disease, which happens with repeated recurrences and more severe inflammation from flares, the harder it is to get that disease under control," Cotton said. "We know that our medications don't work as well in people who have had disease for longer or who have more of a scarring or tunneling burden."

Referral to dermatology may improve long-term outcomes

Cotton cited a retrospective study showing that approximately half of pediatric patients already had scarring or at least 1 tunnel when evaluated by pediatric dermatology specialists.

"We know that this is happening early, this is happening rapidly, and the sooner we can get these kids recognized and referred for appropriate treatment, we know that the better they're going to do, and the better our treatments are going to do," Cotton said.

For pediatricians, these findings highlight the importance of considering HS in adolescents with recurrent inflammatory lesions, even when symptoms do not meet traditional adult diagnostic criteria. Early recognition and referral may help limit disease progression and improve long-term outcomes.

Editor's note: This article is part 1 of a 5-part series for Hidradenitis Suppurativa Awareness Week. Throughout the week, Contemporary Pediatrics will feature expert insights on the recognition, diagnosis, and management of HS in children and adolescents. Check back regularly for additional episodes.

Disclosure: Cotton reports no relevant disclosures

References

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

2. Kittler NW, Williams JC, Kudlinski MV, et al. Evaluation of Hidradenitis Suppurativa Diagnostic Criteria in Pediatric Patients. JAMA Dermatol. 2022;158(12):1404-1408. doi:10.1001/jamadermatol.2022.4564