What is the best short-term and long-term therapy for a patient with recurrent pilonidal hidradenitis suppurativa (Hidradenitis Suppurativa) with scar tissue?

Management of Recurrent Pilonidal Hidradenitis Suppurativa with Scar Tissue

For patients with recurrent pilonidal hidradenitis suppurativa with scar tissue, the most effective treatment approach combines medical therapy with adalimumab for short-term control and surgical intervention for long-term management. 1

Short-Term Management

First-Line Medical Therapy

1. Systemic Antibiotics

   • Tetracyclines: Doxycycline or lymecycline for at least 12 weeks 1

     • Dosage: 100 mg twice daily
     • Suitable for mild-to-moderate disease
     • Consider treatment breaks to assess ongoing need and limit antimicrobial resistance

   • Clindamycin + Rifampicin combination (if unresponsive to tetracyclines) 1, 2

     • Dosage: Clindamycin 300 mg twice daily + Rifampicin 300 mg twice daily
     • Duration: 10-12 weeks
     • Particularly effective for moderate disease with reported improvement in ~80% of cases and remission in ~50% of cases

2. Topical Treatments (adjunctive)

   • Topical clindamycin 1% solution twice daily 1
     • May reduce pustules but carries risk of bacterial resistance
   • Antiseptic washes (chlorhexidine, zinc pyrithione) 1
   • Resorcinol 15% cream 1

3. Intralesional Therapy

   • Intralesional corticosteroid injections for acute inflammatory lesions 1
     • Triamcinolone 10 mg/mL (0.2-2.0 mL) into inflamed lesions
     • Provides rapid reduction in pain, erythema, and edema

For Moderate-to-Severe Disease

1. Biologic Therapy

   • Adalimumab (first-line biologic) 1, 3

     • FDA-approved for moderate-to-severe HS
     • Dosing: 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting at week 4
     • Continue for at least 16 weeks to assess response
     • Significantly improves quality of life and reduces pain

   • Infliximab (if adalimumab fails) 1

     • Dosage: 5 mg/kg at weeks 0,2,6, and then every 8 weeks
     • Second-line biologic option

Long-Term Management

Surgical Interventions

1. Extensive Surgical Excision 1, 4

   • Most effective for long-term control and preventing recurrence
   • Indicated when:
     • Conventional medical treatments have failed
     • Significant scar tissue is present
     • Disease is in destructive or burnout phase
   • Removes all affected tissue including sinus tracts and scarring

2. Healing Options After Excision 1

   • Secondary intention healing
   • TDAP (thoracodorsal artery perforator) flap closure for axillary wounds

3. Deroofing Procedures 5

   • For patients with sinus tracts
   • Less invasive than complete excision
   • Can be combined with medical therapy

Maintenance Therapy

1. Continued Medical Management

   • Long-term antibiotic therapy may be needed for maintenance
   • Dapsone may be effective for long-term maintenance in Hurley stage I or II disease 1
   • Continued biologic therapy in responders

2. Hormonal Therapy (for female patients)

   • Metformin 1
   • Spironolactone 1
   • Estrogen-containing combined oral contraceptives 1
   • Avoid progestogen-only contraceptives (may worsen HS) 1

Special Considerations

Monitoring and Follow-up

• Assess treatment response using inflammatory lesion count, pain scores, and quality of life measures 1
• Monitor for associated comorbidities (depression, anxiety, cardiovascular risk factors) 1
• Screen for fistulating gastrointestinal disease, inflammatory arthritis, and squamous cell carcinoma in long-standing cases 1

Lifestyle Modifications

• Smoking cessation 1
• Weight management 1
• Appropriate wound care and dressings for draining lesions 1

Treatment Algorithm Based on Disease Severity

1. Mild Disease (Hurley I):

   • Tetracyclines for 12 weeks
   • If inadequate response: Clindamycin + Rifampicin for 10-12 weeks
   • Consider localized surgical intervention for persistent lesions

2. Moderate Disease (Hurley II):

   • Clindamycin + Rifampicin for 10-12 weeks
   • If inadequate response: Adalimumab
   • Consider surgical intervention for persistent areas

3. Severe Disease (Hurley III) or Recurrent Disease with Scarring:

   • Adalimumab as first-line therapy
   • Extensive surgical excision
   • Consider combination of medical and surgical approaches

Common Pitfalls to Avoid

1. Delaying Biologic Therapy: For moderate-to-severe disease, early initiation of biologics can prevent disease progression and scarring.

2. Inadequate Surgical Margins: When performing excision, ensure complete removal of all affected tissue to prevent recurrence.

3. Monotherapy Approach: Combining medical and surgical interventions typically yields better outcomes than either approach alone.

4. Incorrect Antibiotic Dosing: Using the combination of clindamycin and rifampicin at proper doses (300 mg twice daily for each) is critical for effectiveness.

5. Overlooking Pain Management: HS is extremely painful; adequate pain control is essential for quality of life.

6. Ignoring Comorbidities: Screen and treat associated conditions that may worsen HS outcomes.