HS Beyond the Skin: What Health Checks Should You Discuss With Your Doctor?

Hidradenitis suppurativa (HS, Acne Inversa) is usually discussed as a skin disease — understandably, since the painful nodulesNodule: A firm, palpable lump deep in tissue. Nodules can be painful and may progress to abscesses. They are among the typical early signs of Acne Inversa.NoduleA firm, palpable lump deep in tissue. Nodules can be painful and may progress to abscesses. They are among the typical early signs of Acne Inversa.Read more in the glossary, abscessesAbscess: An inflamed cavity or swelling containing pus or fluid. In hidradenitis suppurativa, abscesses can form as part of the inflammatory disease process and do not automatically mean that a bacterial infection is present. Secondary bacterial infection can occur and may require separate medical assessment. In Acne Inversa, abscesses occur mainly in the armpits, groin, and other skin folds.AbscessAn inflamed cavity or swelling containing pus or fluid. In hidradenitis suppurativa, abscesses can form as part of the inflammatory disease process and do not automatically mean that a bacterial infection is present. Secondary bacterial infection can occur and may require separate medical assessment. In Acne Inversa, abscesses occur mainly in the armpits, groin, and other skin folds.Read more in the glossary and tunnelsSinus Tract: A tunnel-like channel under the skin that forms between abscesses or nodules. Sinus tracts indicate more advanced disease and can chronically drain fluid. They are associated with Hurley Stages II and III.Sinus TractA tunnel-like channel under the skin that forms between abscesses or nodules. Sinus tracts indicate more advanced disease and can chronically drain fluid. They are associated with Hurley Stages II and III.Read more in the glossary are what is most immediately felt. But research from recent years paints a broader picture: HS occurs alongside a number of other conditions that appear more often in groups of people with HS than in comparison groups — from mental health to heart and metabolic health to joints and gut.

The new European S2k guideline for hidradenitis suppurativa/acne inversa, whose first part was published in 2026, turns this into a structured framework for the first time. Instead of simply listing comorbiditiesComorbidity: An additional condition existing alongside the primary disease. Acne Inversa is frequently associated with comorbidities including metabolic syndrome, inflammatory bowel disease, spondyloarthritis, and depression.ComorbidityAn additional condition existing alongside the primary disease. Acne Inversa is frequently associated with comorbidities including metabolic syndrome, inflammatory bowel disease, spondyloarthritis, and depression.Read more in the glossary, it assigns several areas an explicit recommendation about timing: what should be raised at the first visit, what belongs in regular follow-up, and what is better triggered by symptoms than checked routinely. That is a clear step beyond the predecessor guideline from 2015, which named comorbidities but without a comparable framework for when each area should come up.

This article walks through that framework: which areas it covers, what the underlying evidence shows for each, and — just as importantly — what it does not mean. It is written for people with HS who want to understand why their care team might ask about things that, at first glance, have nothing to do with the skin, and who want to prepare for that conversation.

For information only. This article explains a screening framework drawn from current guidance and literature. It cannot establish whether you have any of the conditions named, and it does not replace an individual clinical assessment.

Key takeaways

• HS is increasingly understood as a systemic inflammatory condition, not an isolated skin problem.
• The new S2k guideline (Part 1, 2026) sets out, for the first time, a structured framework for when HS comorbidities should be raised.
• Mental health, cardiovascular risk and diabetes/metabolic health: first visit and then at least annually.
• Joints, spine and psoriasis: first visit and follow-up visits.
• Gut: when relevant symptoms are present, particularly perianal changes or persistent gastrointestinal symptoms — not routine screening without a prompting symptom.
• None of this is a fixed test panel every person with HS has to go through; it is a framework for the conversation with your care team.

What is new about the 2026 guideline

The European S1 guideline of 2015 was, for over a decade, the central European reference for HS. It already noted that HS occurs alongside a range of associated and secondary conditions — obesity, metabolic syndromeMetabolic Syndrome: A cluster of cardiovascular risk factors — central obesity, raised blood pressure, raised fasting glucose, abnormal cholesterol. Significantly more common in Acne Inversa patients than in the general population, independent of weight alone.Metabolic SyndromeA cluster of cardiovascular risk factors — central obesity, raised blood pressure, raised fasting glucose, abnormal cholesterol. Significantly more common in Acne Inversa patients than in the general population, independent of weight alone.Read more in the glossary, inflammatory bowel diseaseInflammatory Bowel Disease (IBD): Crohn's disease and, less commonly, ulcerative colitis. Acne Inversa patients have a several-fold higher risk of IBD than the general population. If you have HS and unexplained chronic diarrhoea, weight loss, abdominal pain, or perianal disease, a gastroenterology referral is warranted.Inflammatory Bowel Disease (IBD)Crohn's disease and, less commonly, ulcerative colitis. Acne Inversa patients have a several-fold higher risk of IBD than the general population. If you have HS and unexplained chronic diarrhoea, weight loss, abdominal pain, or perianal disease, a gastroenterology referral is warranted.Read more in the glossary, spondyloarthropathy and other hyperergic diseases. What it lacked was a framework for how that knowledge should translate into daily practice: when each area should be raised, at what rhythm, and by whom.

The new guideline appears in two parts. Part 1 (epidemiology, diagnosis and clinical assessment) was published in 2026 in the Journal of the European Academy of DermatologyDermatology: The medical specialty concerned with diagnosing and treating skin conditions. Acne Inversa is often managed by dermatologists, although surgery and other specialties may also be involved.DermatologyThe medical specialty concerned with diagnosing and treating skin conditions. Acne Inversa is often managed by dermatologists, although surgery and other specialties may also be involved.Read more in the glossary and Venereology; Part 2, on treatment, appeared in 2024. Both parts update the 2015 S1 guideline to S2k level — meaning they rest on a structured expert consensus reached through a Delphi process, rather than a formal systematic evidence grading of every point. The authors themselves describe the expansion over the 2015 version as a substantial step forward for the care of people with HS.

For comorbidities specifically, that means: instead of a list of associations, the guideline assigns several areas a recommendation about when assessment should happen. That turns a fairly abstract “HS is linked to X” into something that can actually translate into a practice workflow and a conversation with your doctor.

The screening framework at a glance

Area	Why it matters	When, per the framework	What that can involve
Mental health	Depression and anxietyDepression and Anxiety: Significantly more common in Acne Inversa than in matched controls. Should be screened for as part of comprehensive HS care, not treated as a separate issue.Depression and AnxietySignificantly more common in Acne Inversa than in matched controls. Should be screened for as part of comprehensive HS care, not treated as a separate issue.Read more in the glossary occur more often in HS than in comparison groups	First visit + at least annually	Conversation, possibly a questionnaire
Heart and circulation	Higher rates of cardiovascular risk factors and events	First visit + at least annually	Blood pressure, history, possibly lab values
Diabetes / metabolic health	Metabolic syndrome and type 2 diabetes more common in HS	First visit + at least annually	History, examination, possibly lab values
Joints / spine	Increased risk of inflammatory joint disease/spondyloarthritisSpondyloarthritis: A family of inflammatory joint and spine conditions (including ankylosing spondylitis, psoriatic arthritis) that overlap with Acne Inversa. If you have HS and unexplained inflammatory back pain (morning stiffness lasting more than 30 minutes, better with movement), an assessment is worthwhile.SpondyloarthritisA family of inflammatory joint and spine conditions (including ankylosing spondylitis, psoriatic arthritis) that overlap with Acne Inversa. If you have HS and unexplained inflammatory back pain (morning stiffness lasting more than 30 minutes, better with movement), an assessment is worthwhile.Read more in the glossary	First visit + follow-up visits	History of back pain, examination
Gut	Association with Crohn’s disease/ulcerative colitis	When relevant symptoms are present, especially perianal	Clinical assessment, possibly referral
Psoriasis	Shared inflammatory pathways, associated skin disease	First visit + follow-up visits	Skin examination

The “when” column matters. Three areas — mental health, cardiovascular risk, metabolic health — are described with a recurring, roughly annual rhythm, similar to general preventive care. Three others — joints, psoriasis, and in a sense general disease-course monitoring — are raised at the first visit and at follow-ups, without a fixed yearly cycle. The gut is deliberately handled differently: the emphasis is not on routine screening but on assessment triggered by concrete symptoms — particularly perianal changes or persistent gastrointestinal symptoms.

That distinction is itself an important message: not every comorbidity deserves the same kind of attention, and “comorbidity screening” is not a single blood-panel that runs automatically for every person with HS.

Mental health

Depression and anxiety are among the best-documented psychiatric comorbidities in HS. According to PubMed, a 2019 systematic review and meta-analysis pooling ten studies and 40,307 people with HS found a depression prevalence of 16.9% (95% CI 9.9–27.2%) and an odds ratio of 1.84 (95% CI 1.57–2.15) compared with people without HS (DOI). Anxiety prevalence was 4.9% (95% CI 1.7–13.2%); the available comparison data were insufficient for a reliable odds ratio.

These figures are group-level associations from observational studies — they say depression was found more often in HS populations as a group, not that any one person with HS is automatically affected. The new guideline’s framework calls for mental health to be raised at the first visit and then at least annually — not to screen everyone into a diagnosis, but to give people a recurring, low-friction opening to bring it up. The evidence-based recommendations from the US and Canadian HS Foundations (Garg et al., 2022) name depression, generalized anxiety disorder and suicide risk for similar reasons as areas where screening is recommended in HS.

Shame and body image are a closely related but distinct topic — the companion article on Shame, Body Image and Acne Inversa covers that separately.

Heart and circulation

The cardiovascular dimension of HS is one of the best-supported. A population-based cohort study found roughly double the risk of major adverse cardiovascular events and 1.7- to 2-fold higher cardiovascular-related mortality compared with control subjects. The increased risk is not explained by obesity alone: even after adjusting for BMI, HS contributes independently to cardiovascular risk, a pattern consistent with chronic systemic inflammation as its own risk factor.

The framework therefore calls for a cardiovascular risk assessment at the first visit and then at least annually — blood pressure, history, and, depending on risk profile, lab values such as blood lipids. At its core this is not an HS-specific special test, but a reminder not to neglect general cardiovascular preventive care just because attention is on the skin. The companion article on metabolic syndrome and Acne Inversa covers this in detail, including the exact figures and the biologicalBiologic: A class of medications derived from living cells that target specific components of the inflammatory process. For Acne Inversa, biologics such as adalimumab and secukinumab are used when other treatments are insufficient.BiologicA class of medications derived from living cells that target specific components of the inflammatory process. For Acne Inversa, biologics such as adalimumab and secukinumab are used when other treatments are insufficient.Read more in the glossary explanation.

Diabetes and metabolic health

Closely linked to the cardiovascular picture: metabolic syndrome occurs roughly four times more often in people with HS than in comparable control groups. For individual components, a 2024 meta-analysis reports roughly 2.5-fold higher odds of obesity (OR 2.48) and roughly 2.8-fold higher odds of type 2 diabetes (OR 2.78) in HS.

Here too, the framework calls for a first visit with follow-up checks at least annually: weight and waist circumference, blood pressure (which overlaps with the cardiovascular area), and, depending on risk profile, fasting glucose or HbA1c. Whether laboratory testing is appropriate in an individual case depends on age and individual risk — that is a clinical decision, not an automatic consequence of an HS diagnosis.

Joints and spine

The link between HS and spondyloarthritis — a group of inflammatory joint diseases that includes axial spondyloarthritis and ankylosing spondylitis — is mechanistically well supported and frequently underdiagnosed in practice. Studies report a spondyloarthritis prevalence in HS populations ranging from roughly 1.5% to 40%, with the more plausible estimates clustering around 3% to 8% — compared with under 2% in the general population. The IL-17 inflammatory pathway that is central in HS is also central in spondyloarthritis, providing a clear biological link and explaining why IL-17 inhibitors such as secukinumabSecukinumab: A biologic drug that inhibits the inflammatory messenger interleukin-17A (IL-17A). Secukinumab was approved as the second biologic for treating Acne Inversa and is available under the brand name Cosentyx®.SecukinumabA biologic drug that inhibits the inflammatory messenger interleukin-17A (IL-17A). Secukinumab was approved as the second biologic for treating Acne Inversa and is available under the brand name Cosentyx®.Read more in the glossary and bimekizumabBimekizumab: A monoclonal antibody blocking both IL-17A and IL-17F. Approved by the FDA on 20 November 2024 as the first IL-17A and IL-17F inhibitor for adults with moderate-to-severe HS; approved by the EMA in April 2024. Brand name: Bimzelx®.BimekizumabA monoclonal antibody blocking both IL-17A and IL-17F. Approved by the FDA on 20 November 2024 as the first IL-17A and IL-17F inhibitor for adults with moderate-to-severe HS; approved by the EMA in April 2024. Brand name: Bimzelx®.Read more in the glossary are approved for both conditions.

The framework does not set a fixed yearly rhythm here, but calls for this to be raised at the first visit and at follow-ups: a brief history of inflammatory back pain (insidious onset, morning stiffness over 30 minutes, improvement with movement) and joint symptoms. The companion article on Spondyloarthritis and Acne Inversa describes which symptoms justify a rheumatology referral.

The gut

Inflammatory bowel disease — particularly Crohn’s disease — occurs noticeably more often in HS than in the general population. A population-based Dutch cohort reported an odds ratio of 2.69 (95% CI 1.25–5.79) for Crohn’s disease in people with HS; published prevalence in HS cohorts ranges from 1.2% to 23% depending on the population studied, compared with roughly 0.1–0.3% in the general population. Ulcerative colitis is also elevated, but less strongly and less robustly documented.

Unlike mental health, cardiovascular and metabolic health, the framework does not call for routine screening of everyone here, but for assessment when concrete symptoms are present — especially perianal tunnels or changes that deviate from typical HS locations, as well as persistent diarrhoea, blood in the stool, recurrent abdominal pain, or unintended weight loss. That distinction makes clinical sense: perianal HS and perianal Crohn’s disease can look similar, and telling them apart directly affects treatment decisions. The companion article on Acne Inversa and Inflammatory Bowel Disease goes into this in detail.

Psoriasis

Psoriasis is regularly named in comorbidity-assessment recommendations for HS, partly because both conditions share inflammatory pathways — particularly IL-17 and IL-23 — and because the same biologics (secukinumab, bimekizumab) are approved for both. Unlike joints and the gut, psoriasis in HS does not have as precisely described a prevalence range as spondyloarthritis or Crohn’s disease; the recommendation to raise it at the first visit and at follow-ups rests mainly on the clinical observation that a skin examination is already part of every dermatology appointment.

What this does not mean

It is worth stating plainly what this framework does not stand for.

• It does not mean that every person with HS has, or will develop, any of these conditions.
• It does not mean a fixed lab panel runs routinely for every person with HS — which test is appropriate is decided by individual risk assessment.
• It does not replace a diagnosis. An odds ratio or an elevated prevalence in studies describes a group-level association, not a personal prediction.
• It is not a reason to order your own tests or insist on a specific investigation without a clinical assessment behind it.

The distinction between routine preventive care (mental health, cardiovascular, metabolic) and symptom-triggered assessment (the gut) is itself part of the message: not every comorbidity deserves the same kind of attention, and more screening is not automatically better.

What you can raise at your next appointment

You do not need medical terminology to bring this up. One possible opening:

“I read that the new European HS guideline recommends raising certain comorbidities regularly — things like mental health, cardiovascular risk and metabolic health. Could we go through whether that’s up to date for me?”

Add whatever fits your own situation: unusual back pain, persistent gastrointestinal symptoms, a mood that has felt off, or simply asking when your last general health check-up was. A concrete detail makes the conversation noticeably more useful than the general question alone.

Who is responsible?

No single specialty covers this entire framework, and that is not an accident — it is part of why HS comorbidities are frequently under-addressed in practice. Blood pressure, blood sugar and blood lipids classically belong in general practice; joint symptoms lead to rheumatology; gut symptoms to gastroenterology; mental health can be raised in any of these settings. The dermatology practice treating your HS often sees you most regularly — its role is mainly to flag the need and communicate the HS diagnosis to the other specialties, not to run every test itself. The companion article on your HS care team describes how this coordination can be organised in practice.

What the evidence does not show

Current evidence does not show that:

• every person with HS has, or will develop, one of these comorbidities;
• a single screening interval is equally appropriate for everyone, regardless of age and individual risk;
• successful HS treatment reliably resolves any of these comorbidities, even though better control of systemic inflammation is plausible as an indirect benefit in some areas;
• comorbidity screening in HS is already implemented consistently across routine care — several studies show the opposite, that this is frequently under-delivered.

The bottom line

HS is more than a skin disease, and the new European S2k guideline makes that tangible for the first time with a concrete framework: which areas should be raised when, rather than simply that they are connected at all. The framework is not a checklist to demand, and not a reason to worry that you are automatically affected. It is an invitation to raise a topic that easily gets lost between specialties in routine care — and a reminder that the general preventive care you are already entitled to is worth actually using.