What is the medical management of hidradenitis?

Medical Management of Hidradenitis Suppurativa

The medical management of hidradenitis suppurativa should follow a stepwise approach based on disease severity, with topical clindamycin and tetracyclines for mild disease, clindamycin-rifampin combination for moderate disease, and biologics like adalimumab for severe disease. 1, 2

Disease Assessment

Before initiating treatment, assess disease severity using:

• Hurley Classification:
  • Stage I: Localized abscess without sinus tracts or scarring
  • Stage II: Recurrent abscesses with sinus tract formation and scarring
  • Stage III: Diffuse involvement with multiple interconnected sinus tracts and scarring

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I)

1. First-line therapy:

   • Topical clindamycin 1% solution applied twice daily for 3 months 1, 2
   • Consider antiseptic washes (chlorhexidine) to reduce bacterial resistance 2

2. If inadequate response:

   • Oral tetracycline 500 mg twice daily for up to 4 months 1, 2
   • Doxycycline 100 mg twice daily for 12 weeks 2

3. For acute flares:

   • Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) into inflamed lesions 1
   • Resorcinol 15% cream twice daily during flares and daily between flares 1

Moderate Disease (Hurley Stage II)

1. First-line therapy:

   • Clindamycin 300 mg + rifampin 300 mg, both twice daily for 10-12 weeks 1, 2

2. If inadequate response:

   • Consider hormonal therapy in women:
     • Spironolactone
     • Combined oral contraceptives
     • Metformin (especially with insulin resistance) 2

3. For persistent disease:

   • Consider surgical interventions (deroofing of sinus tracts) 2

Severe Disease (Hurley Stage III)

1. First-line therapy:

   • Adalimumab (FDA-approved): 160 mg at week 0,80 mg at week 2, then 40 mg weekly 2

2. If inadequate response:

   • Infliximab 5 mg/kg at weeks 0,2,6, then every 8 weeks 2
   • Secukinumab (anti-IL-17) 3
   • Bimekizumab (anti-IL-17) 3

3. Adjunctive therapy:

   • Surgical excision of affected areas 2
   • Pain management

Special Populations

Pediatric Patients

• For patients ≥8 years: Oral doxycycline 1
• For patients ≥12 years with moderate-severe disease: Adalimumab 1, 2
• For adolescents: Consider finasteride, especially with endocrine comorbidities 1, 2

Pregnant Patients

• Topical antibiotics and antiseptic washes are generally considered safe 1
• Avoid resorcinol due to potential risks to fetal neurodevelopment 1
• For systemic treatment, cephalexin, azithromycin, and clindamycin are considered safer options 1

Patients with Comorbidities

• HIV: Consider doxycycline (added benefit of STI prophylaxis) and avoid rifampin due to potential drug interactions with antiretroviral therapy 1
• Hepatitis B/C: Use caution with rifampin due to hepatotoxicity risk; ciprofloxacin and co-trimoxazole may be safer options 1
• Malignancy: Doxycycline is generally safe; coordinate with oncology for biologics 1

Lifestyle Modifications

• Weight loss for overweight patients
• Smoking cessation
• Appropriate wound care
• Warm compresses for symptom management

Treatment Challenges and Considerations

• Antibiotic resistance: Topical clindamycin increases risk of bacterial resistance; consider combining with benzoyl peroxide 1
• Treatment duration: Antibiotics typically require 8-12 weeks for optimal response 1
• Recurrence: HS is chronic and often recurs after treatment discontinuation; maintenance therapy may be necessary 1, 3
• Monitoring: Regular follow-up to assess response and adjust treatment as needed

Emerging Therapies

Recent research shows promising results for:

• Subantimicrobial, modified-release doxycycline 40 mg daily (comparable efficacy to regular-dose doxycycline with lower resistance potential) 4
• Novel biologics targeting specific inflammatory pathways 3

The management of hidradenitis suppurativa requires a comprehensive approach tailored to disease severity, with early intervention being crucial to prevent irreversible skin damage and improve quality of life 3.