What are the treatment options for hidradenitis suppurativa?

Treatment Options for Hidradenitis Suppurativa

The first-line treatment for hidradenitis suppurativa includes oral tetracyclines (doxycycline 100 mg once or twice daily or lymecycline 408 mg daily) for at least 12 weeks, with escalation to combination therapy of clindamycin and rifampicin for inadequate response, and biologics such as adalimumab for moderate-to-severe disease. 1

Treatment Algorithm Based on Disease Severity

Initial Assessment and Classification

• Classify severity using Hurley staging system:
  • 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

First-Line Treatment

1. For all severity levels:

   • Topical clindamycin 1% solution twice daily for affected areas 2, 1
   • Oral tetracyclines for 12 weeks (doxycycline 100 mg once/twice daily or lymecycline 408 mg daily) 1
   • Pain management with NSAIDs as needed 2
   • Provide dressings for pus-producing lesions 2

2. For individual inflammatory lesions:

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

Second-Line Treatment (If Inadequate Response After 12 Weeks)

• Combination therapy with oral clindamycin 300 mg twice daily and rifampicin 300 mg twice daily for 10-12 weeks 2, 1
• Consider treatment breaks to assess ongoing need and limit antimicrobial resistance 2

Third-Line Treatment

• For Hurley Stage I-II with inadequate response:

  • Acitretin 0.3-0.5 mg/kg/day (for males and non-fertile females) 2
  • Dapsone as alternative 2
  • Consider localized surgical interventions for persistent lesions 1

• For Hurley Stage II-III with inadequate response:

  • Adalimumab (160 mg initially, 80 mg at week 2, then 40 mg weekly starting at week 4) 1
  • If adalimumab fails, consider infliximab (5 mg/kg at weeks 0,2,6, then every 8 weeks) 1

Fourth-Line Treatment

• Extensive surgical excision for persistent disease despite medical therapy 2, 1
• Consider referral to hidradenitis suppurativa surgical multidisciplinary team 2

Additional Important Considerations

Lifestyle Modifications

• Smoking cessation referral (smoking worsens disease progression) 2, 1
• Weight management referral for overweight patients 2, 1

Monitoring and Comorbidity Management

• Screen for depression/anxiety 2, 1
• Screen for cardiovascular risk factors (measure BP, lipids, HbA1c) 2
• Regular assessment of:
  • Pain (using visual analog scale)
  • Quality of life measures
  • Lesion count
  • Number of flares 2, 1

Emerging Treatments

• Ustekinumab may be considered for patients with HS unresponsive to conventional systemic therapy 2
• Secukinumab and bimekizumab (IL-17 inhibitors) have shown efficacy in moderate-to-severe disease 3

Special Considerations and Pitfalls

Important Cautions

• Monitor for C. difficile colitis with clindamycin use 1
• Screen for latent TB before initiating adalimumab 1
• Avoid tetracyclines in pregnancy and limit to 3 weeks without repeating courses in breastfeeding patients 1
• Acitretin is teratogenic - use only in males or non-fertile females 2

Treatment-Resistant Disease

• Consider combination of medical and surgical approaches for moderate-to-severe disease 3, 4
• Subantimicrobial, modified-release doxycycline (40 mg once daily) has shown comparable efficacy to regular-release doxycycline with lower potential for antibiotic resistance 5

Surgical Options

• Deroofing procedure for recurrent lesions
• Local excision for limited disease
• Wide excision with complete removal of affected tissue for extensive disease 1
• Healing by secondary intention or TDAP flap for extensive excisions 2

By following this structured approach based on disease severity and response to treatment, management of hidradenitis suppurativa can be optimized to improve patient outcomes, reduce pain, and enhance quality of life.