Treatment Options for Hidradenitis Suppurativa
Treatment for hidradenitis suppurativa should be guided by disease severity using the Hurley staging system, with tetracyclines as first-line for mild disease, clindamycin-rifampin combination for moderate disease, and adalimumab for severe disease. 1
Disease Assessment and Staging
Treatment selection depends primarily on disease severity:
- Hurley Stage I (Mild): Localized abscess formation without sinus tracts or scarring
- Hurley Stage II (Moderate): Recurrent abscesses with tract formation and scarring
- Hurley Stage III (Severe): Diffuse involvement with multiple interconnected tracts and abscesses
Baseline documentation should include:
- Pain level using Visual Analog Scale (VAS)
- Quality of life using Dermatology Life Quality Index (DLQI)
- Inflammatory lesion count
- Number of flares in the past month 1
Treatment Algorithm by Disease Severity
Mild Disease (Hurley Stage I)
First-line: Tetracyclines, particularly doxycycline, for 12 weeks 1
- Doxycycline is preferred due to anti-inflammatory properties
- Safe in patients with history of malignancy
- Can be used in patients ≥8 years old
Topical options:
For persistent lesions: Consider localized surgical interventions like deroofing 1
Moderate Disease (Hurley Stage II)
First-line: Clindamycin + Rifampin combination for 10-12 weeks 1
- Response rates of 71-93% reported
- Monitor for severe diarrhea and C. difficile colitis with clindamycin
- Use caution with rifampin in hepatitis B/C patients due to hepatotoxicity risk
- Avoid rifampin in HIV-positive patients due to antiretroviral interactions
If inadequate response: Escalate to adalimumab 1, 3
- Dosing: 160 mg initially, 80 mg at week 2, then 40 mg weekly starting at week 4
- FDA-approved for moderate to severe HS in patients ≥12 years old
Surgical options:
- Nd:YAG laser treatment
- Deroofing for recurrent nodules and tunnels
- Intralesional corticosteroid injections for inflammatory nodules 1
Severe Disease (Hurley Stage III)
- Same dosing as for moderate disease
- Monitor for serious infections including tuberculosis
- Screen for latent TB before initiating therapy
Alternative biologic: Infliximab (5 mg/kg at weeks 0,2,6, then every 8 weeks) 1
Surgical management: Extensive surgical excision with complete removal of all affected tissue 1
Assessing Treatment Response
Evaluate treatment response after 12 weeks using:
- Reduction in inflammatory lesion count
- Improvement in pain levels
- Quality of life measures
If response is inadequate, consider escalating therapy according to the algorithm above 1
Adjunctive Measures
- Antiseptic washes: Chlorhexidine, zinc pyrithione alongside antibiotics 1
- Lifestyle modifications: Smoking cessation and weight management 1
- Screening: Depression, anxiety, cardiovascular risk factors, and inflammatory bowel disease if GI symptoms present 1
- Wound care: Based on drainage amount, location, and periwound skin condition 1
Special Populations
- Pediatric patients: Doxycycline can be used in children ≥8 years old; adalimumab is approved for ≥12 years 1, 3
- Breastfeeding patients: Avoid doxycycline or limit to 3 weeks without repeating courses 1
- HIV patients: Use doxycycline (provides STI prophylaxis benefit); avoid rifampin 1
- Malignancy patients: Use doxycycline and coordinate biologics with oncology 1
Important Cautions
- Biologic therapy risks: Monitor for serious infections, tuberculosis, and malignancy with adalimumab 3
- Antibiotic resistance: Growing concern with long-term antibiotic use; consider alternatives like resorcinol for topical treatment 2, 4
- Avoid simple incision and drainage: Except for acute abscesses to relieve pain; proper surgical techniques are preferred for long-term management 1
- Malignancy risk: Lymphoma and other malignancies have been reported with TNF blockers including adalimumab, particularly in adolescent and young adult males with inflammatory bowel disease who received concomitant azathioprine or 6-mercaptopurine 3