What is the best treatment for hidradenitis?

Best Treatment for Hidradenitis Suppurativa

The best treatment for hidradenitis suppurativa follows a stepwise approach based on disease severity, with oral tetracyclines for mild disease, clindamycin-rifampicin combination for moderate disease, and adalimumab for moderate-to-severe disease that doesn't respond to conventional therapy. 1

Disease Severity Assessment and Treatment Algorithm

Mild Disease (Hurley Stage I)

• First-line treatment:
  • Topical clindamycin 1% solution twice daily 1
  • Oral tetracyclines (doxycycline 100 mg daily or twice daily, or lymecycline 408 mg daily or twice daily) for at least 12 weeks 1
• If inadequate response:
  • Consider localized surgical intervention for persistent lesions 1

Moderate Disease (Hurley Stage II)

• First-line treatment:
  • Clindamycin 300 mg plus rifampicin 300 mg, both twice daily (or clindamycin 300 mg twice daily with rifampicin 600 mg once daily) for 10-12 weeks 2, 1
• If inadequate response:
  • Adalimumab: 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting at week 4 2, 1, 3

Severe Disease (Hurley Stage III)

• First-line treatment:
  • Adalimumab as first-line therapy (same dosing as above) 1, 3
• If inadequate response:
  • Consider extensive surgical excision 1, 4
  • Consider infliximab as second-line biologic therapy (5 mg/kg at weeks 0,2,6 and then every 8 weeks) 1

Surgical Interventions

Surgical options should be considered at all stages of disease, especially for persistent or recurrent lesions:

• Surgical techniques based on disease severity:

  • Deroofing for limited disease 1, 5
  • Local excision for moderate disease 1, 5
  • Wide excision for extensive disease (most effective for complete eradication) 1, 4, 5

• Important surgical considerations:

  • Complete removal of all affected tissue is crucial to prevent recurrence 1
  • Consider healing by secondary intention, skin grafting, or flap closure based on location and extent 1, 5

Adjunctive Therapies

• Lifestyle modifications:

  • Smoking cessation 1
  • Weight management 1

• For female patients:

  • Consider hormonal agents such as spironolactone, metformin, or combined oral contraceptives 1

• Pain management:

  • Essential component of treatment 1
  • May require multidisciplinary approach

Special Considerations

• Treatment monitoring:

  • Regular assessment of inflammatory lesion count, pain levels, and quality of life 1
  • Screen for comorbidities (depression, anxiety, cardiovascular risk factors) 1

• Antibiotic resistance prevention:

  • Consider treatment breaks to assess ongoing need and limit antimicrobial resistance 1
  • Avoid prolonged continuous antibiotic use without breaks 1

• Combination therapy:

  • Evidence supports using biologics in combination with surgery for severe disease 4
  • A multi-tiered approach may be necessary for optimal outcomes 6, 7

Cautions and Contraindications

• For adalimumab:

  • Monitor for serious infections, including tuberculosis 3
  • Screen for latent TB before initiating therapy 3
  • Be aware of potential increased risk of malignancy 3

• For antibiotics:

  • Monitor for side effects of clindamycin, particularly severe diarrhea and C. difficile colitis 1

• Isotretinoin:

  • Should not be offered unless there are concomitant moderate-to-severe acneiform lesions 1
  • May be considered as part of a comprehensive treatment approach in selected cases 8

The evidence strongly supports a stepwise approach to treating hidradenitis suppurativa, with treatment selection based on disease severity and response to previous therapies. For optimal outcomes, combining medical and surgical interventions is often necessary, especially in moderate-to-severe disease.