What is the treatment for a hidradenitis suppurativa flare?

Treatment of Hidradenitis Suppurativa Flares

For acute hidradenitis suppurativa flares, intralesional corticosteroid injection with triamcinolone acetonide (5-10 mg/mL) is the recommended first-line treatment for immediate relief of localized inflammation and pain. 1

Immediate Management of HS Flares

First-line Options

• Intralesional corticosteroids:
  • Triamcinolone acetonide 5-10 mg/mL for immediate relief 1
  • Provides rapid reduction in inflammation and pain
  • Safe and effective for localized flares without systemic symptoms

Pain Management

• Topical resorcinol 15% cream for pain relief 1
• Oral acetaminophen and/or NSAIDs for pain control 1

For Fluctuant Abscesses

• Incision and drainage may be considered for fluctuant, painful abscesses 1
• Note: This differs from regular abscesses as HS flares are primarily inflammatory rather than infectious 2

Systemic Treatment Options

Antibiotics

• For flares with signs of secondary infection or extensive inflammation:
  • First-line: Tetracyclines (doxycycline 100 mg daily or twice daily) for at least 12 weeks 1
  • Second-line: Clindamycin 300 mg + rifampicin 300 mg, both twice daily for 10-12 weeks 1
  • For HIV-positive patients: Consider dapsone or co-trimoxazole due to added prophylactic benefits 3

Biologics for Recurrent or Severe Flares

• Adalimumab is the only FDA-approved biologic for moderate-to-severe HS 4
  • Dosing: 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 starting on Day 29 4
  • Effective for reducing flare frequency and severity 5
  • 90% of patients may still experience at least one flare during treatment, but frequency decreases over time 5

Special Patient Populations

HIV-Positive Patients

• For systemic antibiotics, consider:
  • Oral dapsone (provides prophylaxis against Pneumocystis jirovecii pneumonia) 3
  • Co-trimoxazole (lowers mortality and infection rates in HIV-positive patients) 3
• For biologics: Coordinate care with infectious disease specialists, considering HIV control (viral load, CD4 count) 3

Patients with History of Malignancy

• Use antibiotics cautiously
• Coordinate biologic therapy with oncology 1
• Anti-TNF agents (like adalimumab) should be used with caution in patients with melanoma history 3

Long-term Management After Flare Resolution

Medical Management

• Continue appropriate systemic therapy based on disease severity:
  • Mild (Hurley I): Tetracyclines for 12 weeks
  • Moderate (Hurley II): Clindamycin + Rifampin for 10-12 weeks, adalimumab if inadequate response
  • Severe (Hurley III): Adalimumab as first-line therapy 1

Surgical Options

• For recurrent lesions in the same location, consider deroofing procedures 1
• For severe or refractory disease, extensive surgical excision may be necessary 1, 6

Monitoring and Follow-up

• Regular assessment of inflammatory lesion count, pain levels, and quality of life 1
• Monitor for side effects of medications:
  • For adalimumab: serious infections including tuberculosis 4
  • For clindamycin: severe diarrhea and C. difficile colitis 1

Prevention of Future Flares

• Lifestyle modifications:
  • Weight management
  • Smoking cessation 1
• Maintenance therapy with appropriate medications based on disease severity

Remember that HS flares differ from typical skin infections and require specific management strategies focused on controlling inflammation rather than treating infection alone 2.