Intralesional Steroids Are Effective for Hidradenitis Suppurativa Flares
Intralesional corticosteroid injections are recommended for acute, localized hidradenitis suppurativa flares and should be considered a first-line treatment option for managing these painful inflammatory lesions. 1
Evidence for Intralesional Steroid Use in HS
The North American Clinical Practice Guidelines for Hidradenitis Suppurativa (2025) explicitly support the use of intralesional corticosteroids for acute HS lesions with a conditional recommendation 1. This recommendation applies across various patient populations:
- Adults with HS
- Pregnant patients with HS
- Pediatric patients with HS (with consideration of age, procedural tolerance, and appropriate pain management)
- Patients with history of malignancy
Clinical Efficacy
Multiple studies demonstrate the effectiveness of intralesional corticosteroids for HS flares:
- A prospective case series showed significant reductions in physician-assessed erythema, edema, suppuration, and lesion size after intralesional triamcinolone injection 2
- Patient-reported pain scores decreased significantly after just one day (from 5.5 to 2.3 on visual analog scale) 2
- A multicenter retrospective study of 98 HS patients with 135 injected lesions showed complete response in 70.37% of lesions and partial response in 25.19% 3
Dosing Considerations
- Standard concentration: Triamcinolone acetonide 10 mg/mL 2
- Higher concentrations (20-40 mg/mL) have also shown efficacy with good patient satisfaction and no reported adverse effects 4
Practical Application
For optimal results when using intralesional steroids for HS flares:
- Target acute, localized inflammatory nodules and abscesses
- Consider ultrasound evaluation before injection to improve response rates 3
- Use appropriate pain management and distraction techniques, especially in pediatric patients 1
- Limit to small, bulky, well-localized lesions rather than large or diffuse areas
Important Considerations and Limitations
While intralesional steroids are generally recommended, there are some important caveats:
- One double-blind, randomized, placebo-controlled trial found no significant difference between triamcinolone (10 mg/mL and 40 mg/mL) and normal saline for HS lesion clearance time or pain reduction 5
- Large or diffuse HS lesions may be difficult to treat with intralesional steroids due to:
- Risk of systemic adverse effects with large volumes
- Difficulty distributing the medication evenly throughout large lesions
Alternative and Adjunctive Treatments
For patients with more extensive disease or those who don't respond to intralesional steroids:
- Systemic antibiotics: Tetracyclines (doxycycline) or clindamycin plus rifampin combination 6
- Systemic steroids: Short courses of oral prednisone (0.5-1 mg/kg daily) may be used for severe flares 1
- Biologics: Adalimumab is FDA-approved for moderate-to-severe HS 1, 6
Conclusion
Intralesional corticosteroid injections represent an effective, guideline-supported approach for managing acute HS flares. They provide rapid pain relief and reduction in inflammatory signs, making them a valuable tool in the management of this challenging condition.