From the Guidelines
Hidradenitis suppurativa is a chronic inflammatory skin condition that requires a comprehensive treatment approach, including lifestyle modifications, topical and systemic medications, and surgical interventions, with a focus on improving disease severity, quality of life, and reducing morbidity and mortality risk, as recommended by the most recent guidelines 1.
Diagnosis
The diagnosis of hidradenitis suppurativa is based on clinical presentation, including painful, recurrent nodules, abscesses, and tunnels in the skin, typically in areas where skin rubs together, such as the armpits, groin, buttocks, and under the breasts.
Treatment
Treatment typically begins with lifestyle modifications, including:
- Weight loss if overweight
- Smoking cessation
- Wearing loose clothing
- Using antibacterial soap For mild cases, topical clindamycin 1% applied twice daily for 3 months may help, as suggested by previous studies 1. Moderate cases often require oral antibiotics like doxycycline 100mg twice daily or a combination of clindamycin 300mg twice daily with rifampin 300mg twice daily for 10-12 weeks. Severe or resistant cases may need biologics such as adalimumab (Humira) 40mg weekly after initial loading doses, as recommended by the most recent guidelines 1. Intralesional steroid injections (triamcinolone 5-10mg/ml) can help with acute flares. Surgical options, including incision and drainage, deroofing procedures, or excision, may be necessary for persistent or severe disease. Pain management is important and may include NSAIDs or other analgesics.
Comorbidity Screening
Comorbidity screening is essential in hidradenitis suppurativa, as it is associated with a higher overall comorbidity burden, which influences mortality risk, as highlighted by recent studies 1. Screening is recommended for comorbidities such as:
- Acne
- Dissecting cellulitis of the scalp
- Pilonidal disease
- Pyoderma gangrenosum
- Depression
- Generalized anxiety disorder
- Suicide
- Smoking
- Substance use disorder
- Polycystic ovary syndrome
- Obesity
- Dyslipidemia
- Diabetes mellitus
- Metabolic syndrome
- Hypertension
- Cardiovascular disease
- Inflammatory bowel disease
- Spondyloarthritis
- Sexual dysfunction
By prioritizing morbidity, mortality, and quality of life, and following the most recent guidelines and evidence-based recommendations, healthcare providers can provide optimal care for patients with hidradenitis suppurativa.
From the FDA Drug Label
HUMIRA is indicated for the treatment of moderate to severe hidradenitis suppurativa in patients 12 years of age and older.
The recommended subcutaneous dosage of HUMIRA for adult patients with hidradenitis suppurativa is 160 mg initially on Day 1 (given in one day or split over two consecutive days), 80 mg on Day 15, and 40 mg every week or 80 mg every other week starting on Day 29.
For adolescents 12 years of age and older, the recommended dosage is:
- 30 kg (66 lbs) to less than 60 kg (132 lbs): Day 1: 80 mg, Day 8 and subsequent doses: 40 mg every other week
- 60 kg (132 lbs) and greater: Day 1: 160 mg (given in one day or split over two consecutive days), Day 15: 80 mg, Day 29 and subsequent doses: 40 mg every week or 80 mg every other week
The diagnosis of Hidradenitis suppurativa (Acne inversa) is not explicitly stated in the provided drug labels, but the treatment for moderate to severe hidradenitis suppurativa is indicated as adalimumab (HUMIRA) with specific dosages for adults and adolescents 12 years of age and older 2.
From the Research
Diagnosis of Hidradenitis Suppurativa
- Hidradenitis suppurativa (HS) is a chronic inflammatory disease characterized by painful, deep-seated nodules, abscesses, and draining tunnels in the skin of axillary, inguinal, genitoanal, or inframammary areas 3
- The diagnosis of HS is typically made based on clinical presentation, and the Hurley stage is used to classify disease severity on initial presentation 4
- The International Hidradenitis Suppurativa Severity Score System (IHS4) is used to track changes across visits 4
Treatment of Hidradenitis Suppurativa
- Current treatment includes drug therapy (for the initial, purely inflammatory phase), combined drug and surgical therapy (for the destructive phase), or surgery alone (for the burnout phase) 3
- The combination of oral clindamycin with rifampicin is recommended by European guidelines as a first-line treatment in moderate-to-severe HS 5
- Alternative treatments, such as clindamycin mono-therapy, may be useful in certain cases, especially when rifampicin is not tolerated or is contraindicated 6
- Systemic antibiotics, such as clindamycin and rifampicin, have been shown to be effective in reducing symptoms and improving quality of life in patients with HS 5, 6
- Biologic therapies, such as adalimumab, secukinumab, and bimekizumab, have been approved for the treatment of moderate-to-severe HS and may be used in combination with other therapies 3
Factors Affecting Treatment Response
- High body mass index (BMI) and smoking habits may be predictive factors of a poor response to antibiotics 5
- The presence of clindamycin-resistant bacteria does not appear to affect the efficacy of clindamycin mono-therapy 6
- Combination therapies, such as isotretinoin/spironolactone, isotretinoin or doxycycline with adalimumab, and cyclosporine/adalimumab, may be effective in certain cases of HS 4