What is the first line treatment for Hidradenitis Suppurativa (HS)?

First Line Treatment for Hidradenitis Suppurativa (HS)

The first line treatment for hidradenitis suppurativa depends on disease severity, with topical clindamycin 1% twice daily for 3 months recommended for mild disease (Hurley stage I/mild II) and oral tetracyclines for at least 12 weeks for more widespread disease (moderate HS-PGA or Hurley I/mild II). 1

Treatment Algorithm Based on Disease Severity

Mild HS (Hurley Stage I or mild II, localized disease)

1. First line: Topical clindamycin 1% solution

   • Apply twice daily for 3 months 1
   • Consider treatment breaks to assess ongoing need and limit antimicrobial resistance 1
   • Alternative: Topical resorcinol 15% may be effective and limit antibiotic resistance 2

2. If inadequate response after 3 months:

   • Progress to systemic antibiotics (see moderate HS treatment)

Moderate HS (more widespread Hurley I/mild II or moderate HS-PGA)

1. First line: Oral tetracyclines

   • Doxycycline or lymecycline for at least 12 weeks 1
   • Tetracycline 500 mg twice daily for up to 4 months 1
   • Consider treatment breaks to assess need and limit antimicrobial resistance 1

2. If unresponsive to tetracyclines:

   • Combination therapy: Clindamycin 300 mg twice daily + Rifampicin 300 mg twice daily for 10-12 weeks 1

Severe HS (Hurley II/III or moderate-to-severe disease)

1. If unresponsive to conventional systemic therapy:
   • Adalimumab 40 mg weekly (after loading dose: 160 mg at week 0,80 mg at week 2) 1, 3
   • Note: Adalimumab every other week is NOT recommended 1

Important Clinical Considerations

Disease Assessment

• Use validated instruments to measure treatment response:
  • Hidradenitis Suppurativa Clinical Response (HiSCR)
  • Pain Visual Analogue Scale
  • Quality of life measures 1

Lifestyle Modifications

• Weight management referral where appropriate 1
• Smoking cessation referral where appropriate 1
• These modifications can significantly impact disease course 4

Comorbidity Screening

• Screen for depression, anxiety, cardiovascular risk factors
• Monitor for inflammatory bowel disease if GI symptoms present 1

Pitfalls and Caveats

1. Antibiotic Resistance:

   • Growing concern with long-term antibiotic use 2, 5
   • Consider treatment breaks and alternative therapies when possible

2. Treatment Failure:

   • Recurrence rates are high after discontinuation of antibiotics 6
   • Early escalation to more definitive therapy may be necessary in non-responders

3. Avoid in HS Treatment:

   • Do not offer isotretinoin unless there are concomitant acneiform lesions 1
   • Etanercept is not recommended 1
   • Adalimumab every other week is ineffective 1

4. Surgical Considerations:

   • Medical therapy alone is often insufficient for advanced disease
   • Consider surgical options (extensive excision) for patients with tunnels/scarring or when medical treatments fail 1

Early intervention with appropriate therapy based on disease severity is crucial to prevent irreversible skin damage and improve quality of life in patients with HS 7.