From the Guidelines
Treatment for hidradenitis suppurativa involves a multifaceted approach tailored to disease severity, with the most recent and highest quality study recommending a combination of medical and surgical interventions to manage the condition effectively 1. The approach to managing hidradenitis suppurativa (HS) should be based on the severity of the disease, with mild cases often being managed with topical treatments such as clindamycin 1% solution applied twice daily to control inflammation and infection.
- For moderate disease, oral antibiotics like doxycycline 100mg twice daily or a combination of clindamycin 300mg twice daily with rifampin 300mg twice daily for 10-12 weeks may be necessary.
- In more severe or refractory cases, biologics such as adalimumab (Humira) 40mg weekly after initial loading doses have shown effectiveness by targeting TNF-alpha, a key inflammatory mediator 1.
- Hormonal therapy with spironolactone 50-200mg daily or oral contraceptives may benefit women with menstrual flares.
- Pain management with NSAIDs or acetaminophen is important for symptom control.
- Lifestyle modifications including weight loss, smoking cessation, wearing loose clothing, and avoiding shaving affected areas can reduce flares. Surgical interventions ranging from incision and drainage for acute abscesses to wide excision for chronic disease may be necessary, with wound care being essential after procedures 1. It is crucial to counsel patients about the chronic, relapsing nature of this condition, which affects apocrine gland-bearing skin through follicular occlusion and subsequent inflammation, and to use diagnostic criteria and measures of disease severity such as the Hurley staging system and patient-reported domains like pain and quality of life to guide treatment decisions 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 option for Hidradenitis Suppurativa (HS) is adalimumab (SQ), with the following dosages:
- Adults: 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.
- Adolescents 12 years of age and older:
- 30 kg to less than 60 kg: 80 mg on Day 1, and 40 mg every other week starting on Day 8.
- 60 kg and greater: 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.
From the Research
Treatment Options for Hidradenitis Suppurativa (HS)
The treatment options for HS depend on the morphology, extent, severity, and duration of the disease.
- For mild HS, topical clindamycin and dapsone are often adequate 3.
- For Stage 1 and 2 HS, first-line treatment combines rifampin with either oral clindamycin or minocycline 3.
- Other HS treatments include:
- Fluoroquinolones with metronidazole and rifampin
- Oral dapsone
- Zinc
- Acitretin
- Hormone blockers (oral contraceptive pills, spironolactone, finasteride, and dutasteride)
- Oral prednisone 3
- For severe HS, cyclosporine, adalimumab, or infliximab (used at double psoriatic doses) and intravenous carbapenems or cephalosporins are often required 3.
- Adalimumab, a tumor necrosis factor alpha inhibitor, is effective for patients with moderate to severe HS 4, 5.
- Secukinumab and bimekizumab, which target IL-17, have also been approved for the treatment of moderate-to-severe HS 5.
- Topical resorcinol 15% has been shown to be effective in the management of mild-to-moderate HS, and could be a valid alternative to clindamycin 6.
- Surgical procedures, such as local procedures (punch debridement and unroofing/deroofing) and wide excision, are often necessary for definitive treatment 4, 7.
- Lifestyle modifications, including weight loss, wearing loose-fitting clothes, and smoking cessation, are also important in the management of HS 4.
Medical Therapies
Medical therapies for HS include:
- Antibiotic therapy, such as clindamycin and rifampicin, or ertapenem followed by combination rifampicin, moxifloxacin, and metronidazole 3, 7
- Biologic therapies, such as adalimumab, secukinumab, and bimekizumab 4, 5
- Hormone therapy, such as oral contraceptive pills, spironolactone, finasteride, and dutasteride 3
- Immunomodulatory therapies, such as cyclosporine and infliximab 3
Surgical and Laser Treatments
Surgical and laser treatments for HS include: