What is the diagnosis and treatment for Hidradenitis suppurativa (HS)?

From the Guidelines

Hidradenitis suppurativa treatment should prioritize a holistic evidence-based approach, incorporating lifestyle modifications, topical and systemic medical management, and surgical interventions as needed, with the goal of minimizing morbidity, mortality, and improving quality of life. The treatment of hidradenitis suppurativa (HS) typically begins with lifestyle modifications, including weight loss if overweight, smoking cessation, wearing loose clothing, and good hygiene practices 1. For mild cases, topical treatments like clindamycin 1% solution applied twice daily can help, while moderate cases may require oral antibiotics such as doxycycline or a combination of clindamycin with rifampin for 10 weeks 1.

Key Considerations

• Assessment of disease severity is crucial, using tools like the Hurley classification, and physician-rated assessments such as the Hidradenitis Suppurativa Clinical Response (HiSCR) 1.
• Pain management with NSAIDs or acetaminophen is often necessary, and adjuvant therapy should be offered as needed, including treatment of superinfections and application of appropriate dressings 1.
• Surgical options include incision and drainage for acute abscesses, deroofing procedures for recurrent lesions, or excision of severely affected areas in advanced cases, with the need for surgical intervention assessed in all patients depending on the type and extent of scarring 1.
• Biologics like adalimumab may be prescribed for severe or resistant cases, with a dosing regimen of 160 mg at week 0,80 mg at week 2, and then 40 mg subcutaneously weekly 1.

Treatment Algorithm

• Mild disease: topical clindamycin 1% solution/gel b.i.d. for 12 weeks or tetracycline 500 p.o. b.i.d. for 4 months (LOE IIb, SOR B) 1
• Moderate-to-severe disease: clindamycin 300 p.o. b.i.d. with rifampicin 600 p.o. o.d. for 10 weeks (LOE III, SOR C) or adalimumab 40 mg weekly (LOE Ib, SOR A) 1 Regular follow-up with a dermatologist is essential for monitoring and adjusting treatment as needed, with the goal of minimizing morbidity, mortality, and improving quality of life 1.

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

Adalimumab (HUMIRA) is indicated for the treatment of moderate to severe hidradenitis suppurativa (HS) 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 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

Treatment Options for Hidradenitis Suppurativa

• The combination of systemic clindamycin and rifampicin has been shown to be effective in treating hidradenitis suppurativa (HS) 3, 4, 5.
• This combination therapy has been recommended by European guidelines as a first-line treatment for moderate-to-severe HS 4.
• The efficacy of clindamycin and rifampicin combination therapy has been demonstrated in several studies, with significant improvements in disease severity scores and quality of life 3, 4, 5.

Clindamycin Monotherapy

• Clindamycin monotherapy has also been shown to be effective in treating HS, particularly in patients who cannot tolerate rifampicin or have contraindications to its use 6.
• A study found that clindamycin monotherapy significantly reduced disease severity scores and improved quality of life in patients with HS 6.

Safety and Tolerability

• The combination of clindamycin and rifampicin has been shown to be generally well-tolerated, with most adverse events being mild to moderate 3, 4, 5.
• However, there are concerns about the long-term safety of this combination, particularly with regards to rifampicin-induced liver injury and clindamycin-associated Clostridium difficile infection 7.
• A study found that the risks associated with clindamycin and rifampicin combination therapy are highest in the first 10 weeks of treatment, and that treatment can be continued beyond 10 weeks if clinically necessary 7.

Predictive Factors for Response to Treatment

• High body mass index (BMI) and smoking habits have been identified as predictive factors for a poor response to antibiotic treatment in HS 4.
• A study found that smoking pack-year was positively correlated with disease severity scores and quality of life in patients treated with clindamycin and rifampicin combination therapy 4.