What are the treatment options for hidradenitis suppurativa?

Treatment Options for Hidradenitis Suppurativa

The treatment of hidradenitis suppurativa (HS) should be tailored according to disease severity, with antibiotics for mild disease, combination of clindamycin and rifampin for moderate disease, and adalimumab as first-line biologic therapy for severe disease. 1

Treatment Algorithm Based on Disease Severity

Mild Disease (Hurley Stage I)

• First-line treatment: Tetracyclines (doxycycline 100 mg twice daily) for 12 weeks 1
• For isolated inflamed lesions: Intralesional triamcinolone (10 mg/mL) 1
• Topical options:
  • Clindamycin 1% solution (note: concerns about antibiotic resistance) 1, 2
  • Resorcinol 15% (shown to be more effective than topical clindamycin in mild-to-moderate HS) 2
• Surgical options for persistent lesions: Local excision or deroofing of isolated lesions 1

Moderate Disease (Hurley Stage II)

• First-line treatment: Clindamycin + Rifampin (300 mg twice daily each) for 10-12 weeks 1
  • Response rates of 71-93% for acute abscesses 1
• Second-line treatment: If inadequate response to antibiotics, adalimumab 1, 3
  • Adult dosing: Initial dose of 160 mg on Day 1 (given in one day or split over two consecutive days), followed by 80 mg on Day 15, then 40 mg weekly or 80 mg every other week starting on Day 29 3
• Surgical options: Deroofing of sinus tracts or local excision 1

Severe Disease (Hurley Stage III)

• First-line treatment: Adalimumab 1, 3
  • FDA-approved for moderate to severe HS in patients 12 years and older 3
• Bridge therapy: Triple antibiotic therapy (moxifloxacin, metronidazole, and rifampin) may be used as a bridge to definitive treatment 1
  • Limited efficacy in Hurley stage III (17% complete response) 1
• Definitive treatment: Extensive surgical excision with margins extending beyond visible disease 1
  • Negative pressure wound therapy shows 87% success rate in younger patients 1

Special Populations

Adolescents (12 years and older)

• For moderate-severe disease: Adalimumab with weight-based dosing 1, 3
  • For 30-60 kg: 80 mg on Day 1, then 40 mg every other week starting Day 8 3
  • For ≥60 kg: 160 mg on Day 1 (or split over two days), 80 mg on Day 15, then 40 mg weekly or 80 mg every other week starting Day 29 3
• With endocrine comorbidities: Consider finasteride 1

Patients with Comorbidities

• HIV patients: Doxycycline preferred (added benefit of STI prophylaxis); avoid rifampin due to antiretroviral interactions 1
• Hepatitis B/C: Use rifampin with caution; consider ciprofloxacin or co-trimoxazole 1
• Malignancy: Doxycycline is generally safe; coordinate biologic use with oncology 1

Important Considerations

Treatment Duration and Monitoring

• Antibiotic therapy typically requires 8-12 weeks for optimal response, not the standard 7-10 days used for typical skin infections 1
• Regular assessment of inflammatory lesion count, pain levels, and quality of life measures is essential 1
• TB screening with documented negative test within 12 months is required before starting adalimumab 1, 3

Warnings for Biologic Therapy

• Serious infections: Discontinue adalimumab if serious infection or sepsis develops 3
• Malignancy risk: Lymphoma and other malignancies have been reported with TNF blockers 3

Lifestyle Modifications

• Weight loss for overweight patients 1
• Smoking cessation for all patients 1
• Wearing loose-fitting clothes 4

Surgical Approaches

• Deroofing: For sinus tracts 1
• Local excision: For isolated lesions 1
• Wide excision: For extensive disease, with complete removal of all affected tissue to prevent recurrence 1
• Healing options include secondary intention, skin grafting, or flap closure 1

Common Pitfalls to Avoid

• Inadequate treatment duration: Antibiotics for HS require 8-12 weeks, not the standard 7-10 days 1
• Single-agent antibiotics: Have lower response rates and increased recurrence in advanced disease 1
• Discontinuing treatment too early: Recurrence is common after treatment discontinuation; maintenance therapy may be necessary 1
• Failing to address comorbidities: Screen for depression, anxiety, and cardiovascular risk factors 1
• Delaying biologic therapy: Early intervention with biologics in severe disease may prevent irreversible skin damage 5

Hidradenitis suppurativa is a chronic inflammatory disease with profound negative effects on quality of life 5. Early diagnosis and appropriate treatment based on disease severity are crucial to prevent disease progression and irreversible skin damage 1, 5.