What are the treatment options for hidradenitis suppurativa?

Treatment Options for Hidradenitis Suppurativa

The treatment of hidradenitis suppurativa (HS) should follow a stepwise approach based on disease severity, with antibiotics as first-line for mild-to-moderate disease, adalimumab for moderate-to-severe disease, and surgical interventions for advanced cases. 1

Disease Severity Classification and Initial Approach

Disease severity is typically classified using the Hurley staging system:

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

First-line Treatment Options

For Mild Disease (Hurley I):

• Topical therapy: 1% clindamycin solution applied twice daily to affected areas 2
• Oral antibiotics: Tetracyclines (doxycycline 100 mg or lymecycline 408 mg) once or twice daily for 12 weeks 2, 1
• Localized surgical interventions for persistent lesions 1

For Moderate Disease (Hurley II):

• Combination antibiotic therapy: Clindamycin 300 mg + Rifampin 300 mg, both twice daily for 10-12 weeks 2, 1
• If inadequate response, consider:
  • Acitretin (0.3-0.5 mg/kg/day) for male or non-fertile female patients 2
  • Dapsone as an alternative systemic option 2

For Severe Disease (Hurley III):

• Biologic therapy: Adalimumab as first-line (initial dose of 160 mg on Day 1,80 mg on Day 15, then 40 mg weekly) 1, 3
• Extensive surgical excision with appropriate reconstruction 2, 1

Advanced Treatment Options

Biologic Therapy

• Adalimumab is FDA-approved for moderate-to-severe HS in patients 12 years and older 3
  • Adult dosing: 160 mg on Day 1,80 mg on Day 15, then 40 mg weekly or 80 mg every other week 3
  • Adolescent dosing (≥12 years):
    • 30-60 kg: 80 mg on Day 1, then 40 mg every other week starting Day 8
    • ≥60 kg: 160 mg on Day 1,80 mg on Day 15, then 40 mg weekly or 80 mg every other week 3

Surgical Interventions

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

Hormonal Therapy

For female patients with mild-to-moderate disease or as adjunctive therapy:

• Spironolactone 2, 1
• Metformin 2, 1
• Combined oral contraceptives 2, 1
• Finasteride (particularly for adolescents with endocrine comorbidities) 2, 1

Treatment Considerations for Special Populations

Malignancy History

• Metformin is recommended due to safety and potential survival benefits 2
• Spironolactone, oral contraceptives, and finasteride are suggested as safe options 2
• For biologics, consult with oncology and consider:
  • Anti-TNFs if malignancy in remission >5 years 2
  • Secukinumab or ustekinumab if malignancy within last 5 years 2

Tuberculosis Considerations

• Screen for TB before initiating biologics 2
• Consider non-anti-TNF biologics in high-risk TB patients 2
• Start TB prophylaxis at least 1 month before biologic initiation in latent TB 2

Lifestyle Modifications

• Smoking cessation: Critical as smoking is a significant trigger 1
• Weight management: Weight loss for overweight patients 1
• Screening for comorbidities: Depression, anxiety, and cardiovascular risk factors 2, 1

Treatment Pitfalls and Caveats

1. Delayed escalation: Failing to escalate therapy promptly can lead to disease progression and irreversible scarring 1

2. Antibiotic resistance: Long-term antibiotic use carries risk of resistance; regular monitoring for effectiveness is essential 1

3. Recurrence after treatment cessation: HS commonly recurs after stopping treatment; maintenance therapy may be necessary 1

4. Inadequate surgical excision: Incomplete removal of affected tissue leads to high recurrence rates 1

5. Overlooking comorbidities: HS is associated with metabolic syndrome, inflammatory arthritis, and inflammatory bowel disease due to systemic inflammation 4

6. Insufficient pain management: HS is extremely painful; adequate pain control is essential for quality of life 2, 1

7. Lack of multidisciplinary approach: Complex cases benefit from dermatology, surgery, pain management, and psychological support 5

By following this stepwise approach based on disease severity and considering individual patient factors, hidradenitis suppurativa can be effectively managed to improve quality of life and prevent disease progression.