What is the management of Hidradenitis (hidradenitis suppurativa)?

From the Guidelines

Management of hidradenitis suppurativa involves a multifaceted approach tailored to disease severity, with treatment goals focused on reducing inflammation, preventing new lesions, and managing pain to improve quality of life. For mild disease, topical clindamycin 1% applied twice daily for 3 months can help control symptoms 1. Moderate disease often requires 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 1. For severe or refractory cases, biologics like adalimumab (initial dose 160mg, then 80mg at week 2, followed by 40mg weekly) have shown efficacy 1.

Key Considerations

• Adjunctive treatments include intralesional corticosteroid injections for acute flares and pain management with NSAIDs or acetaminophen.
• Lifestyle modifications are crucial, including weight loss if overweight, smoking cessation, wearing loose clothing, and avoiding shaving affected areas.
• Surgical interventions ranging from incision and drainage for acute abscesses to wide excision for chronic disease may be necessary.

Disease Severity Assessment

• Baseline disease severity in each skin region is often measured using the Hurley staging system 1.
• Patient-reported domains include pain, measured with a visual analogue scale or numeric rating scale (0–10) and quality of life, measured with a dermatology-specific scale such as the DLQI or Skindex 1.

Treatment Algorithm

• The treating physician should be familiar with disease severity scores and use a therapeutic algorithm informed by the evidence available at the time of the review 1.
• A growing body of evidence is being published to guide the treatment of HS, and HS therapy should be based upon the evaluation of the inflammatory components as well as the scarring and should be directed by evidence-based guidelines 1.

Recent Guidelines

• Recent guidelines suggest that adalimumab is currently the only FDA-approved treatment for HS, and its use is recommended to improve disease severity and quality of life in patients with moderate-to-severe HS 1.
• The guidelines also recommend the use of topical and systemic medical treatment, as well as surgical interventions, as part of a comprehensive treatment plan for HS 1.
• The most recent guidelines from 2025 provide expert consensus recommendations on the treatment of HS across special patient populations, including pregnancy, breastfeeding, pediatrics, malignancy, tuberculosis infection, hepatitis B or C infection, and HIV disease 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.

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 Weight Recommended 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 greater 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

Management of Hidradenitis Suppurativa: Adalimumab (HUMIRA) is indicated for the treatment of moderate to severe hidradenitis suppurativa in patients 12 years of age and older. 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. For adolescents 12 years of age and older, the dosage is based on weight. 2

From the Research

Management of 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.

Treatment Approaches

• A comprehensive and updated algorithm for HS management 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 3.
• Current treatment includes drug therapy, combined drug and surgical therapy, or surgery alone, depending on the phase of the disease 4.
• The combination of systemic clindamycin and rifampicin is effective in the treatment of severe HS 5.
• The combination of oral clindamycin with rifampicin is recommended by European guidelines as a first-line treatment in moderate-to-severe HS 6.

Factors Affecting Treatment Response

• High body mass index (BMI) and smoking habits seem to be predictive factors of a poor response to antibiotics 6.
• Smoking pack-year was positively correlated with disease severity and quality of life in patients treated with combination oral clindamycin plus rifampicin 6.
• A positive correlation was found between BMI and disease severity in patients treated with oral clindamycin monotherapy 6.

Multidisciplinary Approach

• A multidisciplinary approach to HS management is recommended, including dermatologists, surgeons, and other healthcare professionals 7.
• Education and awareness of HS are essential for optimal diagnosis and management 7.
• Further clinical research and the establishment of multidisciplinary management teams will continue to advance management of HS 7.