Key takeaways

• Antibiotics, biologics, and surgery address different aspects of hidradenitis suppurativa (HS). Your dermatologist may recommend more than one approach depending on your symptoms and disease severity.

• Antibiotics can reduce inflammation and help manage flares, often over a limited course. Biologics target specific inflammatory pathways to help control moderate to severe HS over time.

• Procedures and surgery can treat persistent tunnels or affected areas that medications alone may not resolve. They may be used alongside biologics.

• If HS remains active despite treatment, your dermatologist may recommend adjusting your medication, switching therapies, or adding a procedure.

• An HS-experienced dermatologist can help you choose and adjust treatment as your condition changes. Seek prompt medical care for fever, rapidly spreading redness, or severe pain.

HS treatment is not always a choice between antibiotics, biologics, and surgery. These approaches work differently and can be combined, particularly for moderate to severe disease. Antibiotics can reduce inflammation during flares, while biologics target the immune pathways that contribute to ongoing disease activity.

Procedures and surgery can address persistent tunnels and damaged tissue. The right treatment depends on your symptoms, disease severity, previous response to therapy, and goals. For more background, see our overview of HS treatments.

Each treatment works on a different part of HS

HS is a long-term inflammatory disease of the skin. It isn't an infection, and it can't be cured. Treatment aims to reduce flares, heal wounds, ease pain, and keep the disease from getting worse.

Each type of treatment does a different job:

• Antibiotics calm a flare by lowering inflammation and bacteria on the skin.

• Biologics control the inflammation that drives new lumps over time.

• Procedures and surgery remove tunnels or damaged skin that have already formed.

On October 20, 2026, the American Academy of Dermatology (AAD) and the HS Foundation published their first joint HS care guidelines. These guidelines strongly recommend four injectable biologics that target the immune system for people with moderate to severe HS. Those four are adalimumab, bimekizumab, infliximab, and secukinumab.

Antibiotics and in-office procedures received a conditional recommendation, which means they help some people and the right choice depends on the person. Your dermatologist weighs your symptoms, past treatment, and goals to decide whether they fit your plan.

How antibiotics, biologics, and surgery compare

This table shows how the three approaches differ in what they do, how they're given, and what to plan for.

What's the difference between antibiotics and biologics for HS?

Both are medicines, but they work on different timelines and in different ways. Antibiotics are a shorter-term tool, while biologics are designed for ongoing control.

How antibiotics help

Antibiotics are a common part of HS care, even though HS isn't an infection. The AAD guide to HS treatment explains that antibiotics are often prescribed because they reduce inflammation and the bacteria that cause flare-ups.

A topical antibiotic called clindamycin is often used for mild HS. When HS is more widespread, dermatologists may prescribe pills such as doxycycline or tetracycline. Another option is clindamycin pills combined with rifampin.

Courses are often limited. A review of antibiotic therapy notes that British, North American, HS ALLIANCE, and Brazilian guidelines suggest a 12-week treatment period. Long courses raise concerns about resistance, which happens when bacteria stop responding to an antibiotic.

Symptoms may return after a course ends. That is one reason antibiotics often aren't the whole long-term plan for moderate to severe HS. They can still be used again later for a flare or alongside other treatments.

How biologics help

Biologics target specific immune signals that drive HS inflammation, rather than lowering your whole immune system. The AAD lists three biologics FDA-approved for adults with moderate to severe HS, which are adalimumab, secukinumab, and bimekizumab. These are given as injections, and most people learn to self-inject at home.

Infliximab is given as an infusion through a vein. It isn't one of the FDA-approved HS biologics, though the 2026 guidelines recommend it for moderate to severe HS.

Biologics are taken on an ongoing basis. Before you start, your dermatologist may order tests, such as a tuberculosis (TB) test, because these medicines can raise the risk of some infections. Your plan may require prior authorization (approval before coverage) or step therapy (trying other medicines first) before it covers a biologic.

Which gives better long-term control

For long-term control of moderate to severe HS, biologics are designed for ongoing use and have the strongest guideline support. Antibiotics are better suited to shorter courses and flares. Many people use both at different times.

Daily habits can support your treatment too. The new AAD and HS Foundation guidelines conditionally recommend quitting tobacco to improve how well treatment works. You can read more about smoking and HS treatment response.

Is surgery or biologic treatment better for severe HS?

Neither is better for everyone. For severe HS, they do different jobs and are often combined.

Biologics calm the inflammation that creates new lumps. Surgery removes tunnels and scarred skin that keep draining.

What surgery and procedures can do

Each procedure fits a different problem:

• Incision and drainage opens a painful abscess to relieve pressure, though the lump may come back.

• Deroofing removes the skin over a tunnel to open and flatten it, often in the office with numbing medicine.

• Wide excision removes a larger area of affected skin, often in an operating room, followed by weeks of wound healing.

Wide excision is used for tunnels or abscesses that persist or keep returning. Surgery treats the area it removes. Medical treatment often continues afterward to control inflammation in the rest of your skin.

A treated area can flare again, and the chance depends on the type of procedure. Dermatologists and surgeons often work together to choose the right procedure and plan the timing.

Why surgery and biologics are often combined

Combining the two addresses both problems. The biologic lowers ongoing inflammation, and surgery clears tunnels that have already formed.

A 2024 systematic review of 8 studies with 733 patients found added benefit from using biologics and surgery together. That benefit was compared with either treatment alone. The evidence is still limited, and research continues.

The 2026 AAD and HS Foundation guidelines conditionally support continuing adalimumab around the time of surgery. Whether to continue your biologic is a decision you make with your dermatologist and surgeon.

What research shows about healing on a biologic

The research on healing is mixed and still developing. It can guide the conversation with your care team, but it doesn't settle every question yet.

In a randomized trial of 206 adults with moderate to severe HS, everyone had wide excision. Compared with placebo, an inactive treatment, adalimumab didn't raise the risk of wound infection, complications, or bleeding.

A 2026 study of 109 surgeries in 77 patients at one center compared people on and off biologics. Healing time, complications, recurrence, and the need for repeat surgery did not differ significantly between the groups.

The 2024 review adds a note of caution, since three of its studies reported slower wound healing with combined treatment. Your care team will plan timing with you based on your health and the procedure.

Options when HS is treatment resistant

Treatment-resistant HS means the disease stays active despite appropriate treatment. This is common, and there are still options to try.

A review summarized by The American Journal of Managed Care notes that loss of response to biologics is common. When that happens, physicians may increase the dose of an FDA-approved medicine or look to medicines approved for other conditions.

Depending on your history, your specialist may suggest:

• Adjusting the dose or schedule of your current biologic

• Switching to a different biologic

• Adding a medicine approved for other conditions

• Adding procedures for tunnels that persist

Each change is directed by your specialist and tailored to you. Research on combining two advanced medicines is still limited.

Adjusting biologic therapy is an active area of HS research. Dr. Mondana Ghias, a board-certified dermatologist and recognized authority in HS who has authored more than two dozen peer-reviewed publications, including award-recognized research advancing the treatment of the disease, is Tono's co-founder and Chief Medical Officer. She was lead author of an original article in the May 2020 Journal of the American Academy of Dermatology on high-dose, high-frequency infliximab for HS.

Questions to ask your dermatologist

A few questions can help you and your dermatologist build a plan that fits your disease. You can open simply by saying, "My flares keep coming back after antibiotics, and I'd like to understand all my options."

• Is my HS mainly active inflammation, tunnels, or both?

• Is a biologic a good fit for me, and what screening do I need first?

• How long should I stay on antibiotics, and what is the plan after?

• Would deroofing or surgery help the areas that keep draining?

• If I have surgery, should I keep taking my biologic?

• How will we know if treatment is working, and what comes next if it isn't?

• What will my insurance need before approving a biologic?

Coverage questions are easier to sort out early. You can review Tono's insurance and access details before your visit.

When to see an HS specialist

It may be time to see a dermatologist experienced in HS when:

• Flares keep returning after antibiotics

• Lumps form tunnels or keep draining

• You've been offered surgery or a biologic and want a full plan

• A biologic has stopped working

Get care right away if you have a fever, redness that spreads quickly, or severe pain.

Tono's HS specialty program covers diagnosis, biologic management, treatment escalation, long-term care, and coordination of procedural care when surgery is needed. Treatment escalation means stepping up care when your current plan isn't controlling the disease. Every HS specialist at Tono is a board-certified dermatologist.

Visits take place by private video, and in-person steps such as procedures are coordinated with you. You can learn more about how virtual-first HS care works.

Tono has cared for more than 20,000 patients across a 33-state clinical footprint. Appointments are available in 2 days or less, no referral is needed, and most insurance is accepted.

A good HS plan is built around your disease over time. It is guided by a specialist who knows your history and adjusts the plan as you go.

Frequently asked questions

Can HS be cured with surgery?

No, surgery can clear the treated area, but HS is a long-term condition. Many people continue medical treatment after surgery to help control the disease elsewhere.

Do I have to stop antibiotics to start a biologic?

Not always. Some people use both for a time, and your dermatologist will decide when the antibiotic can stop.

How long will I need to take a biologic?

A biologic is usually taken on an ongoing basis. Your dermatologist reviews how it's working at regular visits and adjusts the plan if needed.

Does insurance cover HS biologics?

Coverage depends on your plan, which may ask for prior authorization or step therapy first. Tono's care team helps with the prior authorization process.

Schedule an in-person or virtual appointment with a Tono Health specialist

This article is for educational purposes and is not a substitute for medical advice.