Background <p>Hidradenitis suppurativa (HS) is a chronic inflammatory skin disorder increasingly recognized as a systemic disease with significant metabolic comorbidity. Disturbances in lipid metabolism, particularly reduced high-density lipoprotein cholesterol (HDL-C), have been consistently reported in patients with HS. However, the extent to which HDL-C levels are associated with clinical characteristics, systemic inflammatory burden, and disease severity in HS remains insufficiently defined.</p> Methods <p>In this retrospective single-center study, clinical and laboratory data were analyzed for 109 patients with HS and 109 age- and sex-matched healthy controls. Serum lipid parameters were compared between groups. Patients with HS were further stratified according to HDL-C status, and differences in demographic characteristics, clinical features, and laboratory indices were examined to assess the clinical relevance of reduced HDL-C in HS.</p> Results <p>Compared with healthy controls, patients with HS had a significantly higher body mass index (BMI), triglyceride (TG) concentrations and significantly lower HDL-C levels (<i>p</i> &lt; 0.001). Among patients with HS, those with abnormal HDL-C levels exhibited significantly higher BMI, white blood cell count, plateletcrit, gamma-glutamyl transferase, and high-sensitivity C-reactive protein levels than those with normal HDL-C levels (<i>p</i> &lt; 0.05). In addition, axillary involvement was significantly more frequent in the abnormal HDL-C group (<i>p</i> = 0.017). A higher proportion of Hurley stage III disease and higher IHS4 scores were observed in the HDL-C abnormal group.</p> Conclusions <p>Patients with HS demonstrate a characteristic reduction in HDL-C that is associated with elevated systemic inflammatory markers and increased axillary involvement. These findings support HDL-C as a readily accessible indicator of inflammatory burden and disease severity in HS and highlight its potential value in clinical risk stratification.</p>