From ‘nice to have’ to ‘must have’: Integrating ultrasound into routine care of hidradenitis suppurativa

Hidradenitis suppurativa (HS) is characterized by a striking mismatch between what is visible on the skin surface and the true extent of the disease in the dermis and subcutis. Over the last decade, high-frequency and ultra-high-frequency ultrasound (US) have progressively revealed this ‘hidden HS’, providing objective information on tunnels, fluid collections, pseudocysts and follicular alterations that are frequently missed during physical examination alone. The international Delphi consensus by Wortsman et al. represents a crucial step in transforming this body of work into standardized, pragmatic recommendations for daily practice and research in HS.1 As a dermatologist dedicated to HS management, surgery and cutaneous ultrasound, I strongly welcome this consensus. The authors assembled an experienced, truly international panel of HS-US experts across four continents and achieved high levels of agreement on indications, technical requirements, key lesions, scoring systems and pre-interventional planning.1 This validates what many of us have observed in daily practice: ultrasound is no longer an optional add-on, but an indispensable tool to correctly stage, monitor and treat HS.2, 3 Clinically, the most immediate impact is the explicit recommendation to use US to support diagnosis and staging. Multiple studies have shown that purely bedside scores tend to underestimate HS severity compared with sonographic scores.2, 3 By identifying subclinical tunnels, interconnected fluid collections and deep inflammation, bedside US frequently ‘upstages’ patients—especially those labelled Hurley I–II—clarifying bioeligibility for targeted systemic treatment and helping define a therapeutic ‘window of opportunity’ for early disease interception, before irreversible fibrotic tunnelling.2-4 From a surgical perspective, I particularly endorse the recommendation to use US for preoperative and procedural mapping and evaluation of postoperative complications.5 Ultrasound-guided delineation of tunnels improves the accuracy of excision, supports preservation of key anatomical structures, reduces the risk of residual disease and helps anticipate reconstruction needs.5 Beyond anatomy, US supports therapeutic decision-making on timing and sequencing of medical therapy, interventional management or a planned medical-procedural combination. It refines tunnel phenotyping beyond ‘draining/non-draining’ by capturing features such as oedema, Doppler signal, fibrosis and possible internal epithelialization; all of which have prognostic implications (e.g. the ‘double rail/railway’ sign).3-5 Perhaps the most forward-looking aspect of the statement is the call to systematically integrate US into HS clinical trials and longitudinal cohorts.1 Colour/Power Doppler and structural sonographic biomarkers have shown promise in quantifying inflammatory activity and treatment response to biologics.2-4 Incorporating validated US endpoints may refine stratification, reduce heterogeneity and improve interpretability of HS research. Challenges remain, notably access to equipment, competence and the perceived time burden of imaging. The consensus addresses minimal technical and training requirements. However, implementation will require investment, multidisciplinary collaboration and endorsement by national dermatology and HS societies.1 Notably, time consumption decreases with experience and harmonized protocols, improving both efficiency and examination quality.1-5 Future directions include phenotype–ultrasound–histology correlation to link imaging biomarkers with pathophysiology; new devices and software enabling 3D assessment and quantitative measures of fibrosis/inflammation (e.g. elastography-based approaches)4; and AI/ML-assisted segmentation of photographic and ultrasound images to support diagnosis and staging. These advances may improve standardization and shorten consultations, as well as enable personalized medicine, including predictors of progression and response. Thus, more precise combined medical–surgical decisions can be made regarding what to do, when and in whom. In summary, the international consensus by Wortsman et al. convincingly confirms ultrasound as a reliable and established imaging modality for HS and offers concrete guidance for its integration into routine care, surgery and research.1 On the basis of current evidence and experience, US in HS should now be considered a core component of comprehensive management, rather than an optional accessory reserved for specialized units. None. Dr. Vilarrasa has received honoraria and/or travel grants and/or has served as an advisory board member and/or has participated in clinical trials sponsored by AbbVie, Aceleryn, Almirall, Amgen, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Gebro, Incyte, Isdin, Janssen, Leo-Pharma, Lilly, Merck-Serono, MoonLake, MSD, Novartis, Pfizer, Roche, Sandoz, Sanofi, Takeda and UCB. She has also worked as a consultant or participated in clinical trials for iDermApp, Mediktor, DermUS, Biomi, HSCalc and BHH, and was president of the Spanish Group of Hidradenitis Suppurativa. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.