From the Guidelines
Hidradenitis suppurativa treatment should prioritize a holistic evidence-based approach, including lifestyle modifications, topical and systemic medical management, and surgical interventions as needed, with adalimumab being a recommended biologic for moderate-to-severe cases 1.
Overview of Hidradenitis Suppurativa
Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease characterized by painful, recurrent nodules and abscesses that rupture and lead to sinus tracts and scarring. The diagnosis of HS should be made by a dermatologist or other healthcare professional with expert knowledge in HS.
Treatment Approach
The treatment approach for HS depends on the severity of the disease and may include:
- Lifestyle modifications, such as weight loss, smoking cessation, wearing loose clothing, and avoiding irritants
- Topical treatments, such as clindamycin 1% solution applied twice daily for 3 months, for mild cases
- Oral antibiotics, such as doxycycline 100mg twice daily or a combination of clindamycin 300mg twice daily with rifampin 300mg twice daily for 10-12 weeks, for moderate cases
- Biologics, such as adalimumab (Humira) 40mg weekly after initial loading doses, for severe or refractory cases 1
- Surgical interventions, including incision and drainage for acute abscesses, deroofing procedures, or excision of affected areas, may be needed in advanced cases
Biologics in HS Treatment
Adalimumab is currently the only FDA-approved treatment for HS and has been shown to improve disease severity and quality of life in patients with moderate-to-severe HS 1. Other biologics, such as infliximab and ustekinumab, may also be effective for HS, but further studies are needed to determine their optimal dosage and efficacy.
Key Considerations
- Regular follow-up is essential as HS is a chronic condition requiring ongoing management to prevent progression and complications
- The treating physician should be familiar with disease severity scores, such as Hurley staging, and patient-reported outcomes, including DLQI and itch and pain assessment (Visual Analogue Scale) 1
- A therapeutic algorithm informed by the evidence available at the time of the review should be used to guide treatment decisions 1
From the FDA Drug Label
HUMIRA is indicated for the treatment of moderate to severe hidradenitis suppurativa in patients 12 years of age and older.
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
Hidradenitis Suppurativa Treatment with Adalimumab:
- Adalimumab is indicated for the treatment of moderate to severe hidradenitis suppurativa in patients 12 years of age and older 2, 2, 2.
- The recommended dosage for adults 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 2.
- For 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 greater 2.
From the Research
Hidradenitis Suppurativa Overview
- Hidradenitis suppurativa (HS) is a debilitating chronic skin disorder characterized by painful inflammatory nodules, abscesses, and sinus tracts involving intertriginous areas, with an adverse impact on patient quality of life 3.
- The therapeutic options for HS have increased significantly over the past decade, comprising multiple modalities, including topical medication, systemic therapies, surgical approaches, and lifestyle modifications 3.
Treatment Options
- Biologics alone or in combination with surgery remain the treatment of choice for moderate to severe disease, while non-biologic therapies, including retinoids, may be used as monotherapy for mild disease and in combination with biologics and surgical treatment in moderate to severe disease 3.
- A multimodal approach to HS treatment typically involves the use of treatment stacking 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 4.
- Retinoids, specifically isotretinoin, acitretin, and alitretinoin, are historically used in the management of HS, supported by anecdotal evidence and with variable treatment response 3.
Specific Treatments
- Clindamycin as a unique antibiotic choice in HS has shown efficacy in reducing disease severity parameters and pain 5.
- Systemic therapy with immunosuppressive agents and retinoids, including infliximab, adalimumab, and acitretin, has been effective in treating HS, although the quality of evidence is low and differs between agents 6.
- Surgical approaches, including minor excision, carbon dioxide-laser, and major surgery, are recommended for the treatment of fibrotic lesions in HS 7.
Management Algorithm
- A comprehensive and updated algorithm for HS management involves evaluation and diagnosis of HS disease, assessment of severity, extent of disease, and impact on patient quality of life, followed by comorbidity screening and a multimodal approach to treatment 4.
- Adjuvant therapy, including pain management, wound care, and attention, plays a major role in patients' perception of successful treatment and is of practical importance to their coping and self-management 7.