What are the treatment options for hidradenitis suppurativa?

Treatment Options for Hidradenitis Suppurativa

The optimal treatment for hidradenitis suppurativa requires a staged approach based on disease severity, with topical therapies and antibiotics for mild disease, combination antibiotics for moderate disease, and adalimumab for severe disease, along with appropriate surgical interventions for persistent lesions. 1

Disease Severity Assessment

Treatment selection should be guided by disease severity using the Hurley staging system:

• Hurley I (Mild): Localized abscess formation without sinus tracts or 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

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I)

1. First-line options:

   • Topical clindamycin 1% solution 1
   • Antiseptic washes (chlorhexidine, benzoyl peroxide, or zinc pyrithione) 1
   • Resorcinol 15% cream 1
   • Tetracyclines for 12 weeks 1

2. For acute flares:

   • Intralesional triamcinolone (10 mg/mL, 0.2-2.0 mL) 1

3. For persistent lesions:

   • Localized surgical interventions (deroofing) 2, 1

Moderate Disease (Hurley Stage II)

1. First-line therapy:

   • Clindamycin + Rifampin combination for 10-12 weeks 1

2. Second-line options (if inadequate response):

   • Adalimumab 1
   • Surgical options (deroofing, local excision) 2, 1

3. Adjunctive therapies:

   • Nd:YAG laser treatment 2

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

2. Alternative biologic (if adalimumab fails):

   • Infliximab (5 mg/kg at weeks 0,2,6, then every 8 weeks) 1

3. Surgical options:

   • Wide local excision with appropriate reconstruction 2, 1
   • CO₂ laser excision for fibrotic sinus tracts 2

Surgical Management

Surgical options are crucial for managing persistent lesions:

• Incision and drainage: Only recommended for acute abscesses to relieve pain, not as definitive treatment 2
• Deroofing: Recommended for recurrent nodules and tunnels 1
• Wide local excision: Appropriate for extensive chronic lesions with complete removal of all affected tissue 2, 1
• Wound healing options: Secondary intention, primary closure, delayed primary closure, flaps, grafts, or skin substitutes 2

Important: Continuing medical therapy during the perioperative period is beneficial and poses minimal risk of increased postoperative complications 2

Wound Care

• Choose dressings based on drainage amount, location, periwound skin condition, cost, and patient preference 2
• Antiseptic washes are generally supported by expert opinion 2
• Consider negative-pressure therapy for selected large open wounds for 1-4 weeks followed by delayed reconstruction 2

Special Considerations

Adalimumab Safety

• Monitor for serious infections including tuberculosis
• Screen for latent TB before initiating therapy
• Boxed warnings: Serious infections and malignancy risk 3

Antibiotic Considerations

• Clindamycin: Monitor for severe diarrhea and C. difficile colitis 1
• Rifampin: Use caution in patients with hepatitis B/C due to hepatotoxicity risk 1
• Avoid rifampin in HIV-positive patients due to potential drug interactions with antiretroviral therapy 1

Lifestyle Modifications

• Smoking cessation
• Weight management
• Screen for depression and anxiety
• Screen for cardiovascular risk factors (diabetes, hypertension, hyperlipidemia)
• Consider inflammatory bowel disease screening if gastrointestinal symptoms are present 1, 4

Treatment Pitfalls to Avoid

1. Don't rely solely on incision and drainage as it provides only temporary relief and doesn't address the underlying disease 2
2. Don't delay biologic therapy in severe disease as early intervention may prevent disease progression and scarring 1
3. Don't discontinue medical therapy during surgical interventions 2
4. Don't underestimate the importance of wound care in the overall management 2
5. Don't forget to screen for comorbidities that may affect treatment choices 1