What are the treatment options for hidradenitis suppurativa?

Treatment Options for Hidradenitis Suppurativa

For patients with hidradenitis suppurativa, first-line treatment should include oral tetracycline (doxycycline 100 mg once or twice daily) for 12 weeks along with topical clindamycin 1% solution twice daily, with escalation to biologics like adalimumab for moderate-to-severe disease that doesn't respond to antibiotics. 1

Disease Assessment and Staging

Disease severity should be determined using the Hurley staging system to guide treatment decisions:

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

Baseline measurements should include:

• 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:

   • Topical clindamycin 1% solution applied twice daily to affected areas
   • Oral tetracycline (doxycycline 100 mg once or twice daily) for 12 weeks 1
   • Adjunctive measures: dressings for pus-producing lesions, pain management with NSAIDs

2. For inadequate response:

   • Consider combination of oral clindamycin 300 mg twice daily and rifampicin 300 mg twice daily for 10-12 weeks 1, 2

Moderate Disease (Hurley Stage II)

1. First-line therapy:

   • Combination of oral clindamycin 300 mg twice daily and rifampicin 300 mg twice daily for 10-12 weeks 1, 2

2. For inadequate response:

   • Adalimumab: 160 mg initially, 80 mg at week 2, then 40 mg weekly starting at week 4 1, 3
   • Consider localized surgical procedures (deroofing, local excision) for persistent lesions 1

Severe Disease (Hurley Stage III)

1. First-line therapy:

   • Adalimumab: 160 mg initially, 80 mg at week 2, then 40 mg weekly starting at week 4 1, 3
   • Immediate referral to dermatology secondary care 1

2. For inadequate response:

   • Consider infliximab (5 mg/kg at weeks 0,2,6, then every 8 weeks) 1
   • Extensive surgical excision for persistent disease 1

Biologic Therapy Details

Adalimumab (Humira)

• Adult dosing: 160 mg initially (day 1), 80 mg at week 2, then 40 mg weekly starting at week 4 1, 3

• Adolescents (12+ years):

  • 30-60 kg: Day 1: 80 mg, Day 8 and subsequent doses: 40 mg every other week
  • ≥60 kg: Day 1: 160 mg, Day 15: 80 mg, Day 29 and subsequent doses: 40 mg weekly or 80 mg every other week 3

• Important safety considerations:

  • Screen for latent TB before initiating therapy
  • Monitor for serious infections during treatment
  • Be aware of increased risk of malignancy, particularly lymphoma 3

Surgical Options

• Incision and drainage: For fluctuant abscesses
• Deroofing procedure: For recurrent lesions
• Wide excision: For persistent disease despite medical therapy 1

Adjunctive Measures and Lifestyle Modifications

• Wound care: Provide appropriate dressings for pus-producing lesions
• Pain management: NSAIDs as needed
• Lifestyle modifications:
  • Smoking cessation
  • Weight management (if overweight)
  • Wearing loose-fitting clothes 1, 4

Special Considerations

• Pediatric patients: ≥8 years old can be treated with doxycycline
• Breastfeeding patients: Avoid doxycycline or limit to 3 weeks without repeating courses
• HIV patients: Use doxycycline (added benefit of STI prophylaxis); avoid rifampin due to potential drug interactions with antiretroviral therapy
• Patients with malignancy: Use doxycycline and coordinate biologics with oncology 1

Monitoring and Follow-up

• Regular assessment of inflammatory lesion count, pain levels, and quality of life measures
• Screen for depression and anxiety, as well as cardiovascular risk factors
• Monitor for side effects of medications, particularly diarrhea and C. difficile colitis with clindamycin 1

Emerging Treatment Options

Recent research suggests that topical resorcinol 15% may be a valid alternative to clindamycin in managing mild-to-moderate HS, potentially limiting antibiotic use and antimicrobial resistance 5. Additionally, clindamycin-benzoyl peroxide gel has shown similar efficacy to clindamycin lotion and may help prevent antibiotic resistance 6.