What are the treatment options for hidradenitis suppurativa (HS)?

Hidradenitis Suppurativa Management

Treatment for hidradenitis suppurativa should be based on disease severity using the Hurley staging system, with tetracyclines for mild disease, clindamycin plus rifampin for moderate disease, and adalimumab for severe disease. 1

Disease Assessment and Staging

Disease severity should be determined using the Hurley staging system:

• Hurley I (Mild): Localized nodules without sinus tracts
• Hurley II (Moderate): Recurrent nodules 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 by Disease Severity

Mild Disease (Hurley Stage I)

1. First-line: Tetracyclines (particularly doxycycline 100mg twice daily) for 12 weeks
   • Provides anti-inflammatory effects beyond antimicrobial action
   • Safe in patients with history of malignancy
   • Can be used in pediatric patients ≥8 years old 1
2. Topical options:
   • Topical clindamycin 1% solution twice daily for pustular lesions
   • Antiseptic washes (chlorhexidine, zinc pyrithione) 1
3. For persistent nodules:
   • Intralesional corticosteroid injections
   • Deroofing procedures for recurrent lesions 1

Moderate Disease (Hurley Stage II)

1. First-line: Clindamycin 300mg + Rifampin 300mg twice daily for 10-12 weeks
   • Response rates of 71-93% reported
   • Monitor for severe diarrhea and C. difficile colitis with clindamycin
   • Use caution with rifampin in patients with hepatitis B/C due to hepatotoxicity risk 1
2. If inadequate response: Adalimumab (160mg initially, 80mg at week 2, then 40mg weekly) 1, 2
3. Alternative options:
   • Dapsone for mild-to-moderate disease
   • Moxifloxacin + Metronidazole + Rifampin combination for antibiotic failures 1
4. Procedural options:
   • Nd:YAG laser treatment
   • Deroofing for recurrent nodules and tunnels 1

Severe Disease (Hurley Stage III)

1. First-line: Adalimumab (160mg initially, 80mg at week 2, then 40mg weekly)
   • FDA-approved for moderate to severe HS in patients 12 years and older 1, 2
   • Monitor for serious infections including tuberculosis
   • Screen for latent TB before initiating therapy 1, 2
2. Alternative biologics:
   • Infliximab (5 mg/kg at weeks 0,2,6, then every 8 weeks) if adalimumab fails 1
3. For recalcitrant cases:
   • IV Ertapenem as rescue therapy or bridge to other treatments 1
4. Surgical options:
   • Extensive surgical excision with complete removal of affected tissue 1

Special Considerations

Adolescent Patients (12-17 years)

For hidradenitis suppurativa in adolescents, adalimumab dosing is weight-based:

• 30-60kg: 80mg on day 1, then 40mg every other week starting day 8
• ≥60kg: 160mg on day 1 (or split over two days), 80mg on day 15, then 40mg weekly or 80mg every other week 2

Pregnancy and Breastfeeding

• Avoid doxycycline in breastfeeding or limit to 3 weeks without repeating courses
• Adalimumab is pregnancy category B but should be used with caution 1

Patients with HIV

• Doxycycline preferred due to added prophylactic benefit against bacterial STIs
• Avoid rifampin due to potential drug interactions with antiretroviral therapy 1

Patients with Malignancy

• Doxycycline and dapsone are safe options
• Coordinate biologic therapy with oncology 1

Lifestyle Modifications and Adjunctive Care

• Smoking cessation: Critical for improving treatment outcomes
• Weight management: Weight loss can significantly improve symptoms
• Wound care: Appropriate wound care based on drainage amount and location
• Screening: Assess for depression, anxiety, cardiovascular risk factors, and inflammatory bowel disease if GI symptoms present 1

Treatment Response Assessment

Evaluate treatment response after 12 weeks using:

• Reduction in inflammatory lesion count
• Improvement in pain levels
• Quality of life measures

If inadequate response, escalate therapy according to the algorithm above 1

Common Pitfalls to Avoid

1. Simple incision and drainage should be avoided except for acute abscesses to relieve pain, as it does not address the underlying disease and may worsen scarring 1

2. Discontinuing antibiotics too early before adequate trial (minimum 12 weeks for tetracyclines, 10-12 weeks for clindamycin/rifampin) 1

3. Underdosing adalimumab - standard psoriasis dosing is insufficient; HS requires higher dosing (weekly maintenance rather than every other week) 1, 2

4. Neglecting comorbidities - patients should be screened for metabolic syndrome, depression, and inflammatory bowel disease 1