What are the treatment options for hidradenitis suppurativa?

Treatment Options for Hidradenitis Suppurativa

For hidradenitis suppurativa (HS), treatment should follow a stepwise approach based on disease severity, with oral tetracyclines as first-line therapy for mild disease, clindamycin plus rifampicin for moderate disease, and adalimumab for severe disease. 1

Disease Classification and Initial Assessment

• Classify severity using Hurley staging:

  • Stage I (Mild): Localized nodules without sinus tracts
  • Stage II (Moderate): Recurrent nodules with sinus tract formation and scarring
  • Stage III (Severe): Diffuse involvement with multiple interconnected tracts and scarring

• Initial assessment should include:

  • Pain measurement (visual analog scale)
  • Quality of life assessment (e.g., DLQI)
  • Lesion count and number of flares in the last month
  • Screening for depression/anxiety
  • Screening for cardiovascular risk factors

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I)

1. First-line therapy:

   • Topical clindamycin 1% solution twice daily for affected areas 1
   • Oral tetracyclines for 12 weeks:
     • Doxycycline 100 mg once or twice daily, OR
     • Lymecycline 408 mg daily 1

2. For individual inflammatory lesions:

   • Intralesional corticosteroid injections (triamcinolone 10 mg/mL, 0.2-2.0 mL) 1

Moderate Disease (Hurley Stage II)

1. If inadequate response to tetracyclines:

   • Combination therapy with clindamycin 300 mg twice daily and rifampicin 300 mg twice daily for 10-12 weeks 1

2. If inadequate response to antibiotics:

   • Consider acitretin 0.3-0.5 mg/kg/day (for males or non-fertile females) 2
   • Consider dapsone 2

3. If still inadequate response:

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

Severe Disease (Hurley Stage III)

1. First-line therapy:

   • Adalimumab (dosing as above) 1
   • Consider immediate referral to dermatology 2

2. If inadequate response to adalimumab:

   • Infliximab (5 mg/kg at weeks 0,2,6, then every 8 weeks) 1
   • Consider secukinumab 2, 1

3. For extensive disease:

   • Referral to HS surgical multidisciplinary team for extensive excision 2

Surgical Interventions

• For fluctuant abscesses: Incision and drainage for immediate pain relief 1
• For recurrent lesions: Deroofing procedure 1
• For persistent disease despite medical therapy: Extensive excision with complete removal of all affected tissue 1

Pain Management and Wound Care

• NSAIDs or acetaminophen for pain control 1
• Appropriate dressings for pus-producing lesions 2

Lifestyle Modifications

• Smoking cessation (critical for improving outcomes) 2, 1
• Weight management referral if applicable 2, 1

Monitoring and Follow-up

• Assess response after 12 weeks of treatment 2
• Monitor for:
  • Pain levels
  • Quality of life
  • Lesion count and flares
  • Side effects of medications (especially diarrhea with clindamycin and infections with biologics) 1

Special Considerations

• For pediatric patients: Doxycycline can be used in children ≥8 years old 1
• For pregnant/breastfeeding patients: Avoid doxycycline or limit to 3 weeks without repeating courses 1
• For patients with HIV: Use doxycycline; avoid rifampin due to potential drug interactions with antiretroviral therapy 1

Emerging Treatments

Recent evidence supports the use of subantimicrobial, modified-release doxycycline (40 mg once daily), which has shown comparable efficacy to regular-release doxycycline with potentially lower risk of antibiotic resistance 3.

The treatment of HS should aim for early intervention to prevent irreversible skin damage, adequate control of symptoms including pain, and management of extra-cutaneous comorbidities 4.