What are the treatment options for Hidradenitis Suppurativa (HS)?

From the Guidelines

Hidradenitis suppurativa treatment should be tailored to disease severity, with a focus on reducing morbidity, mortality, and improving quality of life, as recommended by the most recent guidelines 1. The treatment approach typically involves a combination of medical and surgical interventions.

• For mild cases, topical clindamycin 1% applied twice daily for 3 months can help control symptoms, as suggested by earlier guidelines 1.
• For moderate disease, oral antibiotics like doxycycline 100mg twice daily or a combination of clindamycin 300mg twice daily with rifampin 300mg twice daily for 10-12 weeks are effective, as recommended by North American clinical management guidelines 1.
• Severe cases may require biologics such as adalimumab (Humira), administered as 160mg initially, then 80mg two weeks later, followed by 40mg weekly, as suggested by earlier studies 1. However, the most recent guidelines 1 emphasize the importance of a multidisciplinary approach, particularly in special patient populations, highlighting the need for tailored treatment strategies to address unique needs and improve outcomes. Key considerations in hidradenitis suppurativa management include:
• Lifestyle modifications: avoiding tight clothing, maintaining a healthy weight, quitting smoking, and using gentle antiseptic washes like chlorhexidine.
• Pain management with NSAIDs or acetaminophen.
• Surgical options: incision and drainage for acute abscesses, deroofing procedures for recurrent lesions, or wide excision for severe disease. These treatments target the underlying inflammation and bacterial colonization in hair follicles and apocrine glands, providing both symptom relief and potential disease modification, ultimately improving morbidity, mortality, and quality of life for patients with hidradenitis suppurativa.

From the FDA Drug Label

Hidradenitis Suppurativa (HS) (1.8): treatment of moderate to severe hidradenitis suppurativa in patients 12 years of age and older. Hidradenitis Suppurativa (2. 6): Adults:◦ Day 1: 160 mg (given in one day or split over two consecutive days)◦ Day 15: 80 mg ◦ Day 29 and subsequent doses: 40 mg every week or 80 mg every other week Adolescents 12 years of age and older: Adolescent WeightRecommended Dosage 30 kg (66 lbs) to less than 60 kg (132 lbs)Day 1: 80 mg Day 8 and subsequent doses: 40 mg every other week 60 kg (132 lbs) and greaterDay 1: 160 mg (given in one day or split over two consecutive days)Day 15: 80 mg Day 29 and subsequent doses: 40 mg every week or 80 mg every other week

Treatment for Hidradenitis Suppurativa (HS): Adalimumab (SQ) is indicated for the treatment of moderate to severe hidradenitis suppurativa in patients 12 years of age and older.

• Adults: The recommended dosage is 160 mg on Day 1,80 mg on Day 15, and 40 mg every week or 80 mg every other week starting on Day 29.
• Adolescents 12 years of age and older: The recommended dosage is based on weight, with 80 mg on Day 1 and 40 mg every other week for those weighing 30 kg to less than 60 kg, and 160 mg on Day 1,80 mg on Day 15, and 40 mg every week or 80 mg every other week for those weighing 60 kg or more 2.

From the Research

Treatment Options for Hidradenitis Suppurativa

• The management of hidradenitis suppurativa (HS) can be challenging and often requires a multimodal approach with the use of on- and off-label medications 3.
• A comprehensive treatment algorithm for HS involves the use of topical therapies, systemic and topical antibiotics, retinoids, hormonal and metabolic therapies, biologics and small molecule inhibitors, systemic immunosuppressants, surgical treatment, pain management, lifestyle modifications, adjunctive treatment, wound care, and flare therapy 3.

Antibiotic Therapies

• The combination of oral clindamycin with rifampicin is recommended as a first-line treatment in moderate-to-severe HS 4, 5.
• Oral clindamycin in monotherapy may be a useful alternative treatment for HS, with studies showing significant reductions in disease severity parameters and pain 6, 7.
• The efficacy of clindamycin plus rifampicin combination therapy is higher than clindamycin monotherapy in some studies, with a higher reduction in disease severity scores and improvement in quality of life 4, 6.

Factors Affecting Treatment Response

• High body mass index (BMI) and smoking habits may be predictive factors of a poor response to antibiotics in HS patients 4, 6.
• Age, BMI, and absence of axillary involvement are factors significantly associated with clinical response to treatment in HS patients 6.

Treatment Outcomes

• Studies have shown that oral clindamycin and rifampicin combination therapy can lead to sustained efficacy in some patients, with clinical response noted in 73% of patients after 12 weeks of treatment 5.
• However, disease relapse can occur after treatment cessation, with 59% of patients experiencing relapse after a mean time of 4.2 months 5.