What are the treatment options for hidradenitis suppurativa?

Treatment for Hidradenitis Suppurativa

The optimal treatment for hidradenitis suppurativa follows a stepwise approach based on disease severity, with first-line therapy consisting of oral tetracyclines and topical clindamycin for mild disease, clindamycin-rifampicin combination for moderate disease, and adalimumab for severe disease. 1

Disease Assessment and Staging

Before initiating treatment, disease severity should be determined using the Hurley staging system:

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

Document baseline measurements including:

• Pain level using Visual Analog Scale (VAS)
• Quality of life using Dermatology Life Quality Index (DLQI)
• Lesion count and number of flares in the last month 1

Treatment Algorithm Based on Disease Severity

Mild Disease (Hurley Stage I)

1. First-line therapy:

   • Oral tetracycline (doxycycline 100 mg once or twice daily) for 12 weeks
   • Topical clindamycin 1% solution twice daily for affected areas 1
   • Alternative topical options: clindamycin-benzoyl peroxide gel (may help prevent antibiotic resistance) 2

2. Adjunctive measures:

   • Dressings for pus-producing lesions
   • Pain management with NSAIDs as needed
   • Localized surgical intervention (deroofing) for persistent lesions 1
   • Topical resorcinol or intralesional corticosteroids for acute flares 3

Moderate Disease (Hurley Stage II)

1. First-line therapy (if inadequate response to tetracyclines):

   • Combination of oral clindamycin 300 mg twice daily and rifampicin 300 mg twice daily for 10-12 weeks (response rates 71-93%) 1, 4

2. Second-line therapy:

   • Adalimumab if inadequate response to antibiotics
   • Dosing: 160 mg initially, 80 mg at week 2, then 40 mg weekly starting at week 4 1, 5

3. Surgical options:

   • Deroofing procedure for recurrent lesions
   • Local excision for persistent lesions 1

Severe Disease (Hurley Stage III)

1. First-line therapy:

   • Adalimumab (FDA-approved for moderate to severe HS)
   • Dosing for adults: 160 mg on day 1 (given in one day or split over two consecutive days), 80 mg on day 15, then 40 mg weekly or 80 mg every other week starting on day 29 1, 5
   • Dosing for adolescents ≥12 years:
     • 30-60 kg: 80 mg day 1, then 40 mg every other week starting day 8
     • ≥60 kg: 160 mg day 1,80 mg day 15, then 40 mg weekly or 80 mg every other week starting day 29 5

2. Alternative biologic therapy:

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

3. Surgical management:

   • Extensive surgical excision with complete removal of all affected tissue 1

Important Considerations and Monitoring

Safety Monitoring

• For adalimumab:

  • Screen for latent tuberculosis before initiating therapy
  • Monitor for serious infections during treatment
  • Be aware of increased risk of malignancy, especially lymphoma 5

• For antibiotics:

  • Monitor for severe diarrhea and C. difficile colitis with clindamycin
  • Consider clindamycin-benzoyl peroxide combination to reduce antibiotic resistance 2

Special Populations

• Pediatric patients: Doxycycline can be used in children ≥8 years old
• Breastfeeding patients: Avoid doxycycline or limit to 3 weeks without repeating courses
• HIV patients: Prefer doxycycline; avoid rifampin due to potential drug interactions with antiretroviral therapy
• Patients with malignancy: Use doxycycline and coordinate biologic therapy with oncology 1

Lifestyle Modifications

• Smoking cessation (critical for treatment success)
• Weight management
• Screen for associated conditions:
  • Depression and anxiety
  • Cardiovascular risk factors (diabetes, hypertension, hyperlipidemia)
  • Inflammatory bowel disease if gastrointestinal symptoms are present 1

Treatment Response Assessment

• Regularly assess inflammatory lesion count, pain levels, and quality of life measures
• Consider treatment modification if inadequate response after appropriate trial period:
  • For antibiotics: 12 weeks for tetracyclines, 10-12 weeks for clindamycin-rifampicin
  • For adalimumab: Evaluate response by 8-12 weeks 1

Remember that early treatment is crucial to prevent disease progression and complications, including scarring and psychological distress. The treatment approach should be adjusted based on response, with escalation to more aggressive therapies if initial treatments fail.