Purpose of Review <p>This review summarizes recent evidence on bacterial and fungal dysbiosis in hidradenitis suppurativa (HS), focusing on how microbiome alterations influence disease pathogenesis and progression. Additionally, the role and effectiveness of antimicrobial treatments in modifying microbial communities and controlling inflammation are evaluated.</p> Recent Findings <p>Emerging studies highlight significant bacterial dysbiosis in HS lesions characterized by decreased commensal species and increased anaerobes. The presence of biofilms in chronic lesions contributes to antibiotic resistance and persistent inflammation. While fungal dysbiosis appears less pronounced, subtle alterations in the mycobiome may influence chronicity or exacerbate disease in susceptible patients. Recent research demonstrates that standard antibiotic regimens remain essential. However, biologics targeting inflammatory cytokines (e.g., TNF-α, IL-17) are increasingly used and may indirectly alter microbial communities.</p> Summary <p>Microbial dysbiosis significantly influences HS pathogenesis by driving chronic inflammation and treatment resistance, especially through biofilm formation. Effective management necessitates combining antimicrobials, biologics, and surgical approaches. Future research should utilize advanced microbiome sequencing to refine targeted treatments and explore microbiome-modulating therapies as adjuncts for sustained clinical remission.</p>