What is the treatment for acute active hidradenitis suppurativa?

From the Guidelines

The treatment for acute active hidradenitis suppurativa involves a combination of approaches, with first-line treatment typically including topical clindamycin 1% solution or oral antibiotics such as tetracycline 500mg twice daily for 4 months, as recommended by the European guidelines for hidradenitis suppurativa 1. The goal of treatment is to reduce inflammation, prevent infection, and promote healing.

• Topical treatments, such as clindamycin 1% solution/gel applied twice daily for 12 weeks, can be effective for mild disease 1.
• For more widespread disease, oral antibiotics such as tetracycline 500mg twice daily for 4 months may be prescribed 1.
• Combination therapy with clindamycin 300mg twice daily and rifampicin 600mg once daily for 10 weeks may be considered for patients who fail to respond to first-line treatment 1.
• Biologics, such as adalimumab 160mg at week 0, 80mg at week 2, and then 40mg subcutaneously weekly, may be prescribed for moderate to severe disease that does not respond to antibiotics 1.
• Lifestyle modifications, including weight loss, smoking cessation, and avoiding shaving affected areas, can also help reduce flares. The most recent and highest quality study, published in 2019, provides a therapeutic algorithm for the medical management of hidradenitis suppurativa, including topical, intralesional, and systemic treatments 1. However, the 2016 European guidelines for hidradenitis suppurativa provide a more comprehensive approach to treatment, including the use of disease severity scores and patient-reported outcomes 1. Therefore, the most effective treatment approach for acute active hidradenitis suppurativa is a holistic, evidence-based approach that incorporates topical and systemic treatments, as well as lifestyle modifications, as recommended by the European guidelines for hidradenitis suppurativa 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

The treatment for acute active hidradenitis suppurativa is adalimumab (SQ). The recommended dosage is:

• For adults:
  • Day 1: 160 mg
  • Day 15: 80 mg
  • Day 29 and subsequent doses: 40 mg every week or 80 mg every other week
• For adolescents 12 years of age and older:
  • For those weighing 30 kg to less than 60 kg:
    • Day 1: 80 mg
    • Day 8 and subsequent doses: 40 mg every other week
  • For those weighing 60 kg and greater:
    • Day 1: 160 mg
    • Day 15: 80 mg
    • Day 29 and subsequent doses: 40 mg every week or 80 mg every other week 2

From the Research

Treatment Options for Acute Active Hidradenitis Suppurativa

The treatment for acute active hidradenitis suppurativa (HS) involves a combination of lifestyle modifications, medical therapies, and surgical interventions.

• Lifestyle modifications:
  • Wearing loose-fitting clothes to reduce friction and irritation 3
  • Losing weight if overweight to reduce pressure on affected areas 3
  • Smoking cessation to reduce inflammation and improve overall health 3
• Medical therapies:
  • Topical clindamycin alone can be effective for patients with mild disease 3
  • Oral antibiotics, such as tetracyclines, in addition to topical clindamycin for patients with moderate disease 3
  • Adalimumab, a tumor necrosis factor alpha inhibitor, for patients with moderate to severe HS 3
  • Subantimicrobial, modified-release doxycycline (MR-DC) as a valuable alternative to other antibiotic regimes, considering its anti-inflammatory properties and lower potential to induce antibiotic resistance 4
• Surgical interventions:
  • Local procedures, such as punch debridement and unroofing/deroofing, for definitive treatment 3
  • Wide excision for patients with severe, extensive disease and scarring 3
  • Laser treatment targeting the hair follicle (neodymium-doped yttrium aluminium garnet or alexandrite) as a standard HS intervention in some countries 5
  • Deroofing of skin tunnels as a standard HS intervention in some countries 5

Considerations for Treatment

When considering treatment options for acute active HS, it is essential to take into account the patient's individual needs, disease severity, and potential comorbidities.

• Patient willingness to receive treatment is strongly influenced by their clinician 5
• Fidelity to oral doxycycline may be low due to lack of effectiveness, participant preference, and adverse effects 5
• Delays in receiving procedural interventions, such as laser therapy and deroofing, are common 5
• Treatment switching is uncommon, and serious adverse events are rare 5

Systemic Antibiotic Therapy

Systemic antibiotic therapy remains a valid therapeutic approach for HS, despite the limitations of antibiotic resistance and toxicity.

• Antibiotics represent the first-line pharmacological treatment of HS due to their anti-inflammatory properties and antimicrobial effects 6
• Future challenges regarding antibiotic therapy in HS comprise their use in association with biologics in the management of acute flare or as a bridge therapy to surgery 6

Biologic Agents

Biologic agents, such as adalimumab, can be effective for patients with moderate to severe HS.

• Biologic agents should be considered in the treatment of resistant cases 7
• Patients with isotretinoin therapy should be alerted for inflammatory low back pain and HS lesions that may develop, and biologic agents may be considered as an alternative treatment option 7