What are the treatment options for hidradenitis suppurativa?

Treatment Options for Hidradenitis Suppurativa

The treatment of hidradenitis suppurativa should follow a stepwise approach based on disease severity, with topical antibiotics for mild disease, oral antibiotics for mild-to-moderate disease, biologics like adalimumab for moderate-to-severe disease, and surgical interventions for advanced cases. 1

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I)

• First-line therapy:
  • Topical clindamycin 1% solution applied twice daily to affected areas 1
  • Tetracyclines (doxycycline 100 mg or lymecycline 408 mg) once or twice daily for 12 weeks 1
• Adjunctive measures:
  • Localized surgical intervention for persistent lesions 1
  • Proper wound care is essential for management 2

Moderate Disease (Hurley Stage II)

• First-line therapy:
  • Combination antibiotic therapy with clindamycin 300 mg + rifampin 300 mg, both twice daily for 10-12 weeks 1, 3
• Second-line therapy:
  • Adalimumab if inadequate response to antibiotics 1, 4
• Alternative options:
  • Acitretin (0.3-0.5 mg/kg/day) for male or non-fertile female patients 1
  • Dapsone for patients with contraindications to other treatments 1
  • Hormonal agents (spironolactone, metformin, combined oral contraceptives) for female patients 1

Severe Disease (Hurley Stage III)

• First-line therapy:
  • Adalimumab: Initial dose of 160 mg on Day 1,80 mg on Day 15, then 40 mg weekly 1, 4
• Second-line therapy:
  • Infliximab for patients unresponsive to adalimumab 1
  • Triple antibiotic therapy (moxifloxacin, metronidazole, and rifampin), though limited efficacy in Hurley stage III (17% complete response) 1
• Surgical options:
  • Extensive surgical excision with appropriate reconstruction 1
  • Deroofing, local excision, or wide excision with complete removal of all affected tissue 1

Biologic Therapy Details

Adalimumab is FDA-approved for moderate to severe hidradenitis suppurativa in patients 12 years and older 4:

Adult Dosing

• Day 1: 160 mg (given in one day or split over two consecutive days)
• Day 15: 80 mg
• Day 29 and subsequent doses: 40 mg weekly or 80 mg every other week 4

Adolescent Dosing (12 years and older)

• 30-60 kg: Day 1: 80 mg; Day 8 and subsequent doses: 40 mg every other week
• ≥60 kg: Day 1: 160 mg; Day 15: 80 mg; Day 29 and subsequent doses: 40 mg weekly or 80 mg every other week 4

Important Considerations

Efficacy of Treatments

• Adalimumab has demonstrated superiority to placebo in reducing disease severity and pain when administered weekly 5
• Combination therapy with clindamycin and rifampicin has shown dramatic improvement in disease severity after 10 weeks of treatment 3

Safety Considerations

• Adalimumab warnings:

  • Increased risk of serious infections including tuberculosis
  • Risk of malignancy, particularly lymphoma
  • Screen for latent TB before initiating therapy 4
  • Monitor for hypersensitivity reactions 4

• Antibiotic therapy:

  • Side effects led to discontinuation in 6.9% of patients using clindamycin-rifampicin combination 3

Special Populations

• Pediatric patients:
  • Doxycycline can be used in children ≥8 years old 1
  • Adalimumab is approved for patients ≥12 years 4
• Breastfeeding patients:
  • Avoid doxycycline or limit to 3 weeks
  • Consider amoxicillin/clavulanic acid, erythromycin, azithromycin, or metronidazole as alternatives 1
• Patients with comorbidities:
  • HIV: Use doxycycline; avoid rifampin due to antiretroviral interactions 1
  • Hepatitis B/C: Use rifampin with caution; consider ciprofloxacin and co-trimoxazole 1

Adjunctive Management

• Screen for and manage comorbidities (depression, anxiety, cardiovascular risk factors) 1
• Smoking cessation and weight management are critical for reducing disease severity 1
• Adequate pain control is essential for improving quality of life 1
• Regular follow-up to assess treatment response and adjust therapy 1

Emerging Treatments

Recent research indicates promising developments in hidradenitis suppurativa treatment, including IL-17 inhibitors (secukinumab and bimekizumab) and IL-1 inhibitors 6, 7. These represent expanding options for patients with moderate-to-severe disease who don't respond to current therapies.