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

Management of Hidradenitis Suppurativa

Treatment of hidradenitis suppurativa (HS) should follow a staged approach based on disease severity, with tetracyclines for mild disease, clindamycin-rifampin combination for moderate disease, and adalimumab for severe disease, alongside appropriate surgical interventions when indicated. 1

Disease Assessment and Staging

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 sinus tract formation and scarring, single or multiple widely separated lesions
• Hurley III (Severe): Diffuse involvement with multiple interconnected sinus tracts and abscesses across entire area

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 last month 1

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I)

1. First-line: Tetracycline antibiotics, particularly doxycycline 100 mg twice daily for 12 weeks 1

   • Beneficial anti-inflammatory properties
   • Safe in patients with history of malignancy
   • Can be used in pediatric patients ≥8 years old

2. Topical options:

   • Topical clindamycin 1% solution twice daily for pustular lesions 1, 2
   • Resorcinol cream for superficial lesions 3, 4

3. For persistent nodules:

   • Intralesional corticosteroid injections 1, 4
   • Deroofing procedure for recurrent lesions 1

Moderate Disease (Hurley Stage II)

1. First-line: Clindamycin 300 mg + Rifampin 600 mg daily for 10-12 weeks 1, 3

   • Response rates of 71-93%
   • Monitor for severe diarrhea and C. difficile colitis with clindamycin
   • Use caution with rifampin in hepatitis B/C patients due to hepatotoxicity risk

2. If inadequate response after 12 weeks:

   • Adalimumab: 160 mg initially, 80 mg at week 2, then 40 mg weekly starting at week 4 1, 5

3. Alternative options:

   • Dapsone for mild-to-moderate disease 1
   • Acitretin (consider teratogenicity in females of reproductive age) 3
   • Nd:YAG laser treatment 1

Severe Disease (Hurley Stage III)

1. First-line: Adalimumab with dosing as above 1, 5, 6

   • FDA-approved for moderate to severe HS in patients ≥12 years old
   • Monitor for serious infections including tuberculosis
   • Screen for latent TB before initiating therapy

2. Alternative biologics:

   • Infliximab 5 mg/kg at weeks 0,2,6, then every 8 weeks 1, 6
   • Note: Higher doses than those used for psoriasis may be required 7

3. For recalcitrant cases:

   • IV Ertapenem as rescue therapy 1
   • Extensive surgical excision 1

Surgical Interventions

• Acute painful abscesses: Incision and drainage for immediate pain relief 1
• Recurrent nodules and tunnels: Deroofing procedure 1
• Persistent sinus tracts: CO2 laser excision 1
• Extensive disease: Wide surgical excision with complete removal of affected tissue 1

Adjunctive Measures

Wound Care

• Appropriate wound care based on drainage amount, location, and periwound skin condition 1, 2
• Antiseptic washes (chlorhexidine, zinc pyrithione) alongside antibiotics 1

Lifestyle Modifications

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

Special Populations

Adolescents (12-17 years)

For moderate to severe HS:

• Weight 30-60 kg: Adalimumab 80 mg day 1, then 40 mg every other week starting day 8
• Weight ≥60 kg: Adalimumab 160 mg day 1 (or split over two days), 80 mg day 15, then 40 mg weekly or 80 mg every other week starting day 29 5

Pregnant/Breastfeeding Patients

• Avoid doxycycline or limit to 3 weeks without repeating courses 1
• Avoid retinoids due to teratogenicity 3

HIV Patients

• Prefer doxycycline (added benefit of STI prophylaxis)
• Avoid rifampin due to potential drug interactions with antiretroviral therapy 1

Treatment Response Assessment

• Evaluate after 12 weeks of therapy
• Measure reduction in inflammatory lesion count, pain levels, and quality of life
• If inadequate response, escalate to next treatment tier 1

Important Considerations and Pitfalls

• Simple incision and drainage alone is insufficient for long-term management and should only be used for acute pain relief 1
• Recurrence rates are high after discontinuation of antibiotic therapy 3
• Adalimumab requires higher dosing for HS than for other inflammatory conditions 5
• Monitor for serious infections and malignancy with biologic therapies 5
• Complete removal of affected tissue is crucial during surgical intervention to prevent recurrence 1