What is the recommended management approach for Hidradenitis (hidradenitis suppurativa)?

Management of Hidradenitis Suppurativa

The recommended management approach for hidradenitis suppurativa requires a stepwise treatment algorithm 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, 2

Disease Classification and Initial Assessment

• Classify disease severity using Hurley staging:

  • Stage I (mild): Isolated nodules without sinus tracts or scarring
  • Stage II (moderate): Recurrent nodules with sinus tract formation and scarring
  • Stage III (severe): Diffuse involvement with multiple interconnected tracts and scarring

• Document:

  • Pain levels using visual analog scale (VAS)
  • Quality of life impact (e.g., DLQI)
  • Inflammatory lesion count
  • Number of flares in the last month 1

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I)

1. First-line therapy:

   • Topical clindamycin 1% solution twice daily 1
   • Oral tetracyclines (doxycycline 100mg daily or twice daily, or lymecycline 408mg daily) for at least 12 weeks 1

2. For acute flares:

   • Intralesional triamcinolone (10 mg/mL) for inflamed lesions 1
   • Warm compresses and antiseptic washes (chlorhexidine, benzoyl peroxide, or zinc pyrithione) 1
   • Topical resorcinol 15% cream (may cause irritant dermatitis) 1

Moderate Disease (Hurley Stage II)

1. First-line therapy:

   • Oral tetracyclines for 12 weeks 1

2. If inadequate response:

   • Combination therapy with oral clindamycin 300mg twice daily and rifampicin 300mg twice daily for 10-12 weeks 1, 2

3. If still inadequate response:

   • Consider acitretin 0.3-0.5 mg/kg/day (for males and non-fertile females) 1
   • Consider dapsone 1

Severe Disease (Hurley Stage III)

1. First-line therapy:

   • Adalimumab (40mg weekly) after initial loading dose (160mg at week 0, 80mg at week 2, then 40mg weekly starting at week 4) 1, 2, 3

2. If inadequate response:

   • Consider infliximab as second-line biologic therapy 2
   • Evaluate for surgical intervention 1

Surgical Interventions

• For limited disease:

  • Deroofing of sinus tracts
  • Localized excision of persistent nodules

• For extensive disease:

  • Wide excision with complete removal of affected tissue
  • Consider healing by secondary intention, skin grafting, or flap closure 1, 2

Adjunctive Measures

1. Lifestyle modifications:

   • Smoking cessation (smoking has an odds ratio of 36 compared to controls) 1, 4
   • Weight management (obesity has an odds ratio of 33 compared to controls) 1, 4
   • Consider dietary modifications (elimination of dairy and brewer's yeast may benefit some patients) 4

2. Pain management:

   • NSAIDs for acute pain
   • Provide dressings for pus-producing lesions 1

3. Comorbidity screening:

   • Depression and anxiety (higher risk of depression and completed suicide) 1
   • Cardiovascular risk factors (diabetes, hypertension, hyperlipidemia) 1
   • Inflammatory bowel disease if gastrointestinal symptoms present 1

Special Populations

Adolescents (12-17 years)

• Adalimumab is FDA-approved for adolescents ≥12 years weighing ≥30kg 3
• For 30-60kg: 80mg on day 1, then 40mg every other week starting day 8
• For ≥60kg: 160mg on day 1 (or split over two days), 80mg on day 15, then 40mg weekly or 80mg every other week starting day 29 3

Pregnant Women

• Topical treatments and procedural interventions should be first-line
• Retinoids and hormonal therapies are contraindicated
• Certain immunosuppressants should be avoided 1

Monitoring Treatment Response

• Reassess at 12 weeks:

  • Pain levels (VAS)
  • Quality of life measures
  • Inflammatory lesion count
  • Number of flares in the last month 1

• For patients on antibiotics:

  • Consider treatment breaks to assess ongoing need and limit antimicrobial resistance 1, 2

• For patients on adalimumab:

  • Monitor for serious infections, including tuberculosis
  • Screen for latent TB before initiating therapy 2

Clinical Pitfalls and Caveats

1. Antibiotic resistance: Topical clindamycin increases rates of Staphylococcus aureus resistance; consider combining with benzoyl peroxide to reduce this risk 1

2. Treatment expectations: Inform patients that most treatments suppress rather than cure HS, and that combination of medical and surgical approaches may be needed for optimal outcomes 5

3. Scarring: Early intervention is crucial to minimize scarring and disease progression, particularly in pediatric patients 1

4. Comorbidities: HS is associated with nearly doubled risk of cardiovascular-associated death compared to controls, making screening for cardiovascular risk factors essential 1

5. Surgical timing: Consider surgical interventions for persistent or recurrent lesions despite optimal medical therapy, as fibrotic lesions generally do not respond to medical treatment 5