From the Guidelines
Treatment options for hidradenitis suppurativa include both medical and surgical approaches, with adalimumab being a recommended biologic therapy for moderate to severe disease, as supported by the North American clinical management guidelines 1. The treatment of hidradenitis suppurativa (HS) depends on the severity of the disease. For mild cases, topical treatments like clindamycin 1% solution applied twice daily can help control inflammation. Oral antibiotics are often first-line therapy, with tetracyclines (doxycycline 100mg twice daily) or a combination of clindamycin 300mg twice daily with rifampin 300mg twice daily for 10-12 weeks showing effectiveness, as recommended by the European guidelines for hidradenitis suppurativa 1.
Medical Management
For moderate to severe disease, anti-inflammatory medications like tumor necrosis factor (TNF) inhibitors, particularly adalimumab (Humira) at 40mg weekly after initial loading doses, are FDA-approved and can significantly reduce inflammation and pain, as shown in the PIONEER 1 and PIONEER 2 trials 1.
- Adalimumab is currently the only FDA-approved treatment for HS, with a recommended dosing of 160 mg at week 0,80 mg at week 2, and then 40 mg weekly starting at week 4 1.
- Other biologic therapies, such as infliximab, anakinra, and ustekinumab, may also be effective for HS, but require further study to determine optimal dosing and efficacy 1.
Surgical Management
Surgical interventions range from incision and drainage for acute abscesses to wide excision of affected areas for chronic, scarred disease.
- Lifestyle modifications are also important, including weight loss if overweight, smoking cessation, wearing loose clothing, and avoiding shaving affected areas.
- Pain management should be addressed with appropriate analgesics.
Comorbidity Screening
Comorbidity screening is also essential in the management of HS, with recommendations to screen for conditions such as acne, dissecting cellulitis of the scalp, pilonidal disease, pyoderma gangrenosum, depression, generalized anxiety disorder, suicide, smoking, substance use disorder, polycystic ovary syndrome, obesity, dyslipidemia, diabetes mellitus, metabolic syndrome, hypertension, cardiovascular disease, inflammatory bowel disease, spondyloarthritis, and sexual dysfunction, as supported by the US and Canadian Hidradenitis Suppurativa Foundations 1. These treatments work by targeting different aspects of the disease process, including bacterial colonization, inflammation, and hormonal influences that contribute to the characteristic painful nodules, abscesses, and sinus tracts in apocrine gland-bearing skin.
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 (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 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
Treatment Options for 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 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 treatment of hidradenitis suppurativa (HS) can be challenging and often requires a multimodal approach with the use of on- and off-label medications 3. The following are some of the treatment options available:
- 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
- Flare therapy
Medications Used in Treatment
Several medications have been approved for the treatment of HS, including:
- Adalimumab, which targets TNF 4
- Secukinumab and bimekizumab, which target IL-17 4
- Ustekinumab, which has been used as an alternative treatment for patients who do not respond to other medications, including anti-TNF drugs 5
- Clindamycin and rifampicin, which are recommended by European guidelines as a first-line treatment in moderate-to-severe HS 6
Factors Affecting Treatment Response
Several factors can affect the response to treatment, including:
- Body mass index (BMI), which has been found to be positively correlated with AISI in patients treated with oral clindamycin 6
- Smoking habits, which have been found to be predictive of a poor response to antibiotics 6
Approach to Management
A consensus document has been developed to provide guidance for the evaluation and management of patients with HS, which includes statements and recommendations on diagnosis and assessment, treatment and management, comorbidities and a multidisciplinary approach, and education 7. The document suggests that antibacterial and anti-tumour necrosis factor therapies are effective in the treatment of HS, and that further clinical research and the establishment of multidisciplinary management teams will continue to advance management of HS.