What are the treatment options for hydradenitis suppurativa?

Treatment Options for Hidradenitis Suppurativa

For hidradenitis suppurativa (HS), treatment should follow a stepwise approach based on disease severity, with topical clindamycin for mild disease, oral tetracyclines for mild-to-moderate disease, clindamycin-rifampicin combination for moderate disease, and adalimumab for moderate-to-severe disease that doesn't respond to conventional therapy. 1

Treatment Algorithm Based on Disease Severity

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
• Surgical options: Localized surgical intervention (deroofing, local excision) for persistent lesions 1

Moderate Disease (Hurley Stage II)

• First-line treatment:
  • Clindamycin 300 mg plus rifampicin 300 mg, both twice daily, for 10-12 weeks 1, 2
• Second-line treatment:
  • Adalimumab if inadequate response to antibiotics 1, 3
  • Dosing: 160 mg at week 0,80 mg at week 2, and 40 mg weekly starting at week 4 1

Severe Disease (Hurley Stage III)

• First-line treatment:
  • Adalimumab as first-line therapy 1, 3
  • Adult dosing for HS: 160 mg on day 1 (given in one day or split over two consecutive days), 80 mg on day 15, then 40 mg weekly or 80 mg every other week 3
• Surgical option:
  • Extensive surgical excision for persistent disease 1

Special Populations

Adolescents (12 years and older)

• Adalimumab dosing based on weight: 3
  • 30-60 kg: 80 mg on day 1, then 40 mg every other week starting on day 8
  • ≥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 on day 29

Additional Treatment Options for Female Patients

• Hormonal agents: 1
  • Spironolactone
  • Metformin
  • Combined oral contraceptives

Important Safety Considerations

For Adalimumab

• Serious infection risk: Monitor for infections including tuberculosis; perform TB screening before initiating therapy 3
• Malignancy risk: Increased risk of lymphoma and other malignancies 3
• Hypersensitivity: Monitor for anaphylaxis or serious hypersensitivity reactions 3

For Antibiotics

• Clindamycin: Monitor for severe diarrhea and C. difficile colitis 1
• Antibiotic resistance: Avoid prolonged continuous antibiotic use without treatment breaks 1

Lifestyle Modifications

• Critical interventions: 1
  • Smoking cessation
  • Weight management
  • These modifications significantly reduce disease severity and improve quality of life

Treatment Monitoring

• Regularly assess:
  • Inflammatory lesion count
  • Pain levels
  • Quality of life measures 1
• Screen for comorbidities (depression, anxiety, cardiovascular risk factors) 1

Common Pitfalls to Avoid

1. Inadequate treatment duration: Ensure tetracyclines are given for at least 12 weeks and clindamycin-rifampicin for 10-12 weeks 1
2. Failure to escalate therapy: Don't delay advancing to biologics when conventional therapy fails 1
3. Overlooking surgical options: Consider surgical interventions for persistent lesions even while on medical therapy 1
4. Neglecting pain management: A multidisciplinary approach to pain control is essential for quality of life 1
5. Missing TB screening: Always screen for latent TB before starting adalimumab 3

The evidence strongly supports a structured approach to HS treatment based on disease severity. While topical and oral antibiotics remain effective for mild-to-moderate disease, adalimumab has demonstrated significant efficacy for moderate-to-severe disease and is the only FDA-approved biologic therapy for HS 1, 3.