What are the treatment options for hidradenitis suppurativa?

Treatment Options for Hidradenitis Suppurativa

The treatment of hidradenitis suppurativa should follow 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 is guided by 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 twice daily
   • Antiseptic washes
   • Resorcinol 15% cream
   • Tetracycline antibiotics (doxycycline 100mg twice daily) for 12 weeks 1

2. For persistent lesions:

   • Localized surgical interventions (deroofing)
   • Intralesional triamcinolone (10 mg/mL, 0.2-2.0 mL) for acute flares 1

Moderate Disease (Hurley Stage II)

1. First-line therapy:

   • Clindamycin 300mg twice daily + Rifampin 600mg daily for 10-12 weeks 1, 2
   • Response rates of 71-93% reported in systematic reviews 1

2. If inadequate response:

   • Adalimumab: 160mg initially, 80mg at week 2, then 40mg weekly starting at week 4 1, 3

Severe Disease (Hurley Stage III)

1. First-line therapy:

   • Adalimumab: 160mg initially, 80mg at week 2, then 40mg weekly starting at week 4 1, 3

2. Alternative biologic option if adalimumab fails:

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

3. Surgical management:

   • Extensive surgical excision with complete removal of all affected tissue 1

Surgical Interventions

• Incision and drainage: Only for acute abscesses to relieve pain, not as definitive treatment 1
• Deroofing: Recommended for recurrent nodules and tunnels 1
• CO₂ laser excision: Useful for fibrotic sinus tracts 1
• Wide local excision: For extensive chronic lesions with appropriate reconstruction 1

Important Considerations with Medical Therapy

Antibiotics

• Tetracyclines: Avoid in children under 8 years; limit to 3 weeks in breastfeeding patients 1
• Clindamycin + Rifampin: 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
• Rifampin: Avoid in HIV-positive patients due to potential drug interactions with antiretroviral therapy 1

Biologics (Adalimumab)

• Dosing for adolescents with HS (12 years and older):

  • 30-60kg: Day 1: 80mg, Day 8 and subsequent doses: 40mg every other week
  • ≥60kg: Day 1: 160mg, Day 15: 80mg, Day 29 and subsequent: 40mg weekly or 80mg every other week 3

• Safety monitoring:

  • Screen for latent TB before initiating therapy
  • Monitor for serious infections during treatment
  • Be aware of increased risk of lymphoma and other malignancies 1, 3

Adjunctive Measures

• Wound care: Choose dressings based on drainage amount, location, and periwound skin condition 1
• Lifestyle modifications: Smoking cessation and weight management 1
• Screening: Depression, anxiety, cardiovascular risk factors, and inflammatory bowel disease if gastrointestinal symptoms are present 1

Clinical Pearls and Pitfalls

• Do not discontinue medical therapy during surgical interventions 1
• High BMI and smoking appear to be predictive factors of poor response to antibiotics 4
• HS requires a multifaceted approach as lesions include both inflammation (amenable to medical treatment) and fibrosis (amenable to surgery only) 5
• Early treatment is crucial to reduce disease complications and improve quality of life 6
• Adalimumab is currently the only FDA-approved medication specifically for HS treatment 3, 6