What is the initial treatment option for hidradenitis suppurativa?

Initial Treatment Options for Hidradenitis Suppurativa

The first-line treatment for hidradenitis suppurativa is oral tetracyclines such as doxycycline 100 mg once or twice daily for at least 12 weeks. 1, 2

Disease Assessment and Classification

Before initiating treatment, it's important to classify the severity of hidradenitis suppurativa (HS) using the Hurley staging system:

• Hurley Stage I (Mild): Localized abscess formation without scarring or sinus tracts
• Hurley Stage II (Moderate): Recurrent abscesses with tract formation and scarring, single or multiple widely separated lesions
• Hurley Stage III (Severe): Diffuse involvement with multiple interconnected tracts and abscesses

Initial Treatment Algorithm

First-Line Therapy

• Oral tetracyclines (doxycycline 100 mg daily or twice daily, or lymecycline 408 mg daily) for at least 12 weeks 1
  • These have anti-inflammatory properties beyond their antimicrobial effects
  • Consider treatment breaks to assess ongoing need and limit antimicrobial resistance

Topical Therapy (Adjunctive)

• Topical clindamycin 1% solution twice daily for affected areas 1
  • The only topical antibiotic with evidence in HS
  • A 12-week randomized controlled trial showed reduction in pustules but not inflammatory nodules 1
  • May cause irritant dermatitis in some patients 1

For Acute Flares

• Intralesional corticosteroid injections (triamcinolone 10 mg/mL, 0.2-2.0 mL) for individual inflammatory lesions 1
  • Significant reduction in erythema, edema, suppuration, and size
  • Pain reduction can occur within 1 day 1

Treatment for Inadequate Response to First-Line Therapy

If there is inadequate response to tetracyclines after 12 weeks:

• Combination of oral clindamycin 300 mg twice daily and rifampicin 300 mg twice daily for 10-12 weeks 1, 2
  • Systematic review reported response rates of 71-93% 1
  • Strong recommendation in guidelines 1

Additional Considerations

Pain Management

• Assess pain using a visual analog scale (VAS)
• Provide appropriate analgesics (NSAIDs or acetaminophen) 1, 2
• Provide dressings for pus-producing lesions 1

Lifestyle Modifications

• Offer smoking cessation referral if applicable 1
• Offer weight management referral if applicable 1
• These modifications can significantly impact disease progression

Screening for Comorbidities

• Screen for depression and anxiety 1, 2
• Screen for cardiovascular risk factors (diabetes, hypertension, hyperlipidemia) 1
• Consider inflammatory bowel disease screening if gastrointestinal symptoms are present 1

Monitoring Response

Assess treatment response after 12 weeks using:

• Pain scores
• Quality of life measures
• Lesion count
• Number of flares in the last month 1

Common Pitfalls to Avoid

1. Delayed referral to dermatology: Patients with Hurley stage III disease should be referred promptly to dermatology 1

2. Prolonged antibiotic use without breaks: This increases risk of antimicrobial resistance 1, 2

3. Using isotretinoin as first-line therapy: Guidelines specifically recommend against using isotretinoin unless there are concomitant moderate-to-severe acneiform lesions 1

4. Inadequate pain management: Pain control is essential for improving quality of life 2

5. Missing associated comorbidities: HS is associated with several systemic conditions that require screening 1, 2

By following this structured approach to initial management of hidradenitis suppurativa, focusing on oral tetracyclines as first-line therapy with appropriate adjunctive treatments, patients can experience significant improvement in their condition and quality of life.