A 6-year-old girl presented with precocious puberty. She developed painful inflamed nodules in the groin at 7 years. During the subsequent year, she had an increase in the number and size of these lesions. She was initially treated by her community physician with topical and oral antibiotics with no success. She also had been taking a 4-month course of isotretinoin, which did not improve her HS lesions. At the time she presented to us at age 13 years, she had extensive lesions consistent with HS in the groin and axillae. There were large, tender, inflamed nodules extending to the perianal, perineal regions, and inner thighs. Surgical resection of tissue from the left axilla was explored as an option for extensive axillary disease, but ultimately the surgical team suggested to pursue medical management. She continued to develop extensive lesions in the axillae, flanks, groin, and inner thighs. She was started on oral minocycline with no significant improvement. Two months later, she was given oral Marvelon (ethinyl estradiol, 0.03 mg, and desogestrel, 0.15 mg, on menstrual cycle days 1 through 21). Six months later, there was mild to moderate improvement, and oral spironolactone was added to augment her therapy. At 13½ years of age, she continued to have further flares, requiring oral cephalexin on 2 occasions. At age 14 years, she had a significant flare-up in the axillae, groin, lower abdomen, and inner thighs, requiring a 6-week course of oral cephalexin. She was experiencing considerable emotional distress as a result of her skin disease. She commenced photodynamic therapy at age 14½ years, and minocycline was switched to tetracycline hydrochloride, in addition to spironolactone, and oral contraceptive (OC). She underwent amino levulinic acid photodynamic therapy (ALA-PDL) monthly. Initially, there was minimal improvement with ALA-PDL. At 15¼ years, spironolactone was stopped and finasteride, 5 mg/d, was started and increased 3 months later to 10 mg/d. In conjunction with ALA-PDL and OCs, escalation of finasteride to 10 mg/d resulted in clinical improvement with reduction in frequency and severity of flares. Oral tetracycline hydrochloride was stopped 6 months after maximum finasteride dose was achieved. During the next 3 years, she had only 3 flares, each of which were treated successfully with brief courses of oral cephalexin. She has currently been receiving this treatment for 6 years.