What is the treatment for cellulitis secondary to hidradenitis suppurativa?

Treatment for Cellulitis Secondary to Hidradenitis Suppurativa

For cellulitis secondary to hidradenitis suppurativa, oral tetracyclines (doxycycline or lymecycline) for at least 12 weeks should be the first-line treatment, followed by combination therapy with clindamycin and rifampicin if inadequate response occurs. 1, 2

First-Line Treatment

• Oral tetracyclines:
  • Doxycycline 100mg twice daily or lymecycline 300mg twice daily for at least 12 weeks 1, 2
  • Consider treatment breaks to assess ongoing need and limit antimicrobial resistance 1
  • Tetracyclines have shown significant improvement in Hidradenitis Suppurativa Score (HSS) in prospective studies 3

Second-Line Treatment

• Combination therapy if unresponsive to tetracyclines:
  • Clindamycin 300mg twice daily + Rifampicin 300mg twice daily for 10-12 weeks 1, 2
  • This combination has shown dramatic improvement in Sartorius scores in studies with 116 consecutive patients 4
  • Monitor for severe diarrhea and C. difficile colitis with clindamycin 2
  • Use caution with rifampicin in patients with hepatitis B/C due to hepatotoxicity risk 2

Third-Line Treatment Options

• For moderate-to-severe disease unresponsive to antibiotics:

  • Adalimumab 40mg weekly (licensed for adults and children/young people aged 12-17 years) 1, 2
  • Consider infliximab 5mg/kg every 8 weeks if adalimumab is ineffective 1, 2
  • Biologic therapy has shown efficacy in special scenarios including cases complicated by cellulitis 5

• Alternative options:

  • Acitretin 0.3-0.5 mg/kg/day in males and non-fertile females unresponsive to antibiotics 1
  • Dapsone in patients unresponsive to antibiotic therapies 1

Management of Acute Flares

• For acute flares with cellulitis:
  • Intralesional triamcinolone (10 mg/mL, 0.2-2.0 mL) can rapidly reduce erythema, edema, suppuration, and pain 2
  • Provide appropriate dressings for pus-producing lesions 1
  • Consider penicillins with β-lactamase inhibitors or fluoroquinolones for acute cellulitis based on antibiogram studies 6

Surgical Interventions

• For persistent disease despite medical therapy:
  • Consider surgical options including incision and drainage, deroofing, or wide local excision 2
  • Radical surgical excision may be necessary for recurrent cases, with reconstruction using grafts or flaps showing lower recurrence rates than primary closure 7

Important Considerations

• Manage via a multidisciplinary team approach, particularly when considering surgical interventions 1
• Screen for associated comorbidities including depression, anxiety, and cardiovascular risk factors 1, 2
• Refer to smoking-cessation and weight-management services where relevant 1, 2
• Measure treatment response using recognized instruments for pain and quality of life 1

Special Population Considerations

• Pregnancy: Avoid tetracyclines; consider cephalexin, azithromycin, or clindamycin monotherapy 2
• HIV patients: Use doxycycline; avoid rifampicin due to potential interactions with antiretroviral therapy 2
• Pediatric patients: Doxycycline can be used in children ≥8 years old 2

Treatment Algorithm Based on Disease Severity

1. Mild disease (Hurley I):

   • Tetracyclines for 12 weeks
   • If inadequate response → combination therapy

2. Moderate disease (Hurley II):

   • Tetracyclines for 12 weeks
   • If inadequate response → clindamycin + rifampicin for 10-12 weeks
   • If still inadequate → adalimumab

3. Severe disease (Hurley III):

   • Consider immediate referral to dermatology secondary care 1
   • Adalimumab as first-line therapy
   • Consider extensive surgical excision