What is the best approach for managing Hidradenitis Suppurativa?

Management of Hidradenitis Suppurativa

The best approach for managing hidradenitis suppurativa (HS) is a stepwise treatment strategy based on disease severity, with adalimumab being the recommended biologic therapy for moderate-to-severe disease that is unresponsive to conventional therapy. 1

Treatment Algorithm Based on Disease Severity

Mild Disease (Hurley Stage I)

1. First-line therapy:

   • Oral tetracyclines (doxycycline 100 mg daily or twice daily) for at least 12 weeks 1
   • Topical clindamycin for limited disease 2
   • Lifestyle modifications: weight management and smoking cessation 1

2. For persistent lesions:

   • Localized surgical interventions (incision and drainage, deroofing) 1

Moderate Disease (Hurley Stage II)

1. First-line therapy:

   • Combination of clindamycin (300 mg twice daily) and rifampin (600 mg daily) for 10-12 weeks 1, 3
   • This combination has shown dramatic improvement in disease severity scores 3

2. For inadequate response:

   • Adalimumab: 160 mg initially (Day 1), 80 mg at week 2, then 40 mg weekly starting at week 4 1, 4

Severe Disease (Hurley Stage III)

1. First-line therapy:

   • Adalimumab with dosing as above 1, 4
   • Consider extensive surgical excision for definitive management 1

2. Alternative biologics:

   • Infliximab (5 mg/kg at weeks 0,2,6, then every 8 weeks) if adalimumab fails 1
   • Secukinumab may be considered in select patients 5

Special Patient Populations

Pregnant Patients

• Recommended biologic: Adalimumab (strong recommendation, moderate evidence) 5
• Alternative biologic options:
  • Infliximab (conditional recommendation) 5
  • Secukinumab (conditional recommendation) 5
  • Certolizumab for patients concerned about in-utero biologic exposure 5
• Antibiotic considerations:
  • Avoid oral doxycycline (risk of congenital anomalies) 5
  • Avoid oral erythromycin (risk of elevated liver enzymes) 5
• Anti-androgens: Metformin is safe for use in pregnancy 5

Breastfeeding Patients

• Antibiotic options:
  • Rifampin, amoxicillin/clavulanic acid, erythromycin, azithromycin, metronidazole 5
  • Use oral clindamycin with caution (risk of GI side effects in infant) 5
  • Limit doxycycline use to 3 weeks without repeating courses 5, 1
• Anti-androgens:
  • Metformin is safe during breastfeeding 5
  • Oral contraceptives when contraception is also desired 5

HIV-Positive Patients

• Consider dapsone or co-trimoxazole for added prophylactic benefits against Pneumocystis jirovecii pneumonia 1
• Coordinate biologic therapy with infectious disease specialists 1
• Avoid rifampin due to potential drug interactions with antiretroviral therapy 1

Antibiotic Resistance Considerations

Antibiotic resistance is an important concern in HS management:

• Patients using topical clindamycin may develop clindamycin-resistant Staphylococcus aureus 6
• Ciprofloxacin use may lead to ciprofloxacin-resistant MRSA 6
• Trimethoprim/sulfamethoxazole use may lead to resistant Proteus species 6
• Tetracyclines and oral clindamycin show less significant antimicrobial resistance 6

Nonstandardized antibiotic treatment can shift the microbiology of skin lesions toward gram-negative bacteria, suggesting that trimethoprim-sulfamethoxazole or ciprofloxacin (alone or with rifampin) may be effective options for patients previously treated with multiple antibiotics 7.

Pain Management

• Oral acetaminophen and/or NSAIDs for pain control 1
• For severe pain, consider consultation with pain management specialists 1

Monitoring and Follow-up

• Regular assessment of inflammatory lesion count, pain levels, and quality of life measures 1
• Screen for comorbidities including depression, anxiety, and cardiovascular risk factors 1
• When using biologics like adalimumab, monitor for serious infections and screen for latent TB before initiating therapy 1, 4
• Monitor for side effects of antibiotics, particularly with clindamycin (risk of C. difficile colitis) 1

By following this evidence-based approach and tailoring treatment to disease severity and special patient populations, clinicians can optimize outcomes for patients with hidradenitis suppurativa.