Mild hidradenitis suppurativa (HS) remains a therapeutic gray zone in dermatology. While severe disease often warrants biologics or surgical intervention, early-stage HS is frequently managed with repeated cycles of systemic antibiotics or corticosteroids—approaches that may be disproportionate to disease severity and carry well-documented adverse effects. As awareness grows about the chronic, inflammatory nature of HS, interest is increasing in safer, targeted topical therapies that may interrupt disease activity earlier and more sustainably.

The Limitations of Conventional Therapy in Mild HS

For patients with mild HS—typically characterized by recurrent inflammatory nodules without extensive sinus tracts or scarring—first-line treatment often includes topical clindamycin. When flares persist, clinicians commonly escalate to oral antibiotics or short courses of systemic steroids.

However, these strategies are not without cost. Repeated antibiotic exposure contributes to antimicrobial resistance, disrupts the microbiome, and may offer diminishing returns over time. Systemic corticosteroids, though effective in suppressing inflammation, are unsuitable for long-term use due to metabolic, immunologic, and psychological side effects. For a condition that is chronic and relapsing, this creates a clear treatment gap between minimal intervention and overtreatment.

HS as an Inflammatory Disease: A Rationale for Topical Anti-Inflammatories

Hidradenitis suppurativa is no longer viewed simply as an infectious process. Current understanding emphasizes follicular occlusion followed by dysregulated innate immune responses, with elevated levels of proinflammatory cytokines such as TNF-α, IL-1β, and IL-17. This evolving pathophysiologic model raises an important question: if inflammation is central from the earliest stages, could targeted anti-inflammatory therapy—delivered topically—alter the disease course?

Topical anti-inflammatory agents offer several theoretical advantages. They act locally at the site of disease, minimize systemic exposure, and may be suitable for long-term or maintenance use. For patients with mild HS, such an approach could reduce reliance on systemic medications while still addressing the underlying inflammatory drive.

Emerging Evidence From Case Series and Early Studies

Recent case series have begun to explore the role of novel topical anti-inflammatory creams in mild HS. These formulations typically combine agents with immunomodulatory properties designed to suppress local cytokine activity and reduce inflammatory infiltration of the follicular unit.

In reported cases, patients experienced reductions in lesion count, pain, and erythema after several weeks of consistent topical application. Importantly, improvements were observed without the adverse effects commonly associated with systemic antibiotics or steroids. While these findings are preliminary and derived from small patient populations, they provide a signal that topical anti-inflammatory therapy may be both feasible and clinically meaningful.

Clinical Implications and Patient Selection

If further validated, anti-inflammatory topical creams could occupy an important niche in HS management. They may be particularly well suited for:

• Patients with early or mild disease (Hurley stage I)

• Individuals experiencing frequent flares who wish to avoid systemic therapy

• Long-term maintenance after disease control has been achieved

• Patients with contraindications to antibiotics or steroids

That said, topical therapy is unlikely to replace systemic treatment in moderate to severe HS. Instead, it may function as part of a stepwise, personalized treatment strategy—intervening earlier in the disease process and potentially preventing progression.

Looking Ahead: A Shift Toward Safer, Earlier Intervention

The growing interest in topical anti-inflammatory therapy reflects a broader shift in HS management: moving away from repeated short-term suppression and toward sustained, mechanism-based control. While large randomized controlled trials are still needed, early clinical experience suggests that topical anti-inflammatory creams may help bridge the gap between under-treatment and overtreatment in mild hidradenitis suppurativa.

For patients and clinicians alike, the promise is compelling—a safer, more targeted option that aligns with the chronic inflammatory nature of the disease and the long-term needs of those living with it.