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

Treatment Options for Hidradenitis Suppurativa

For hidradenitis suppurativa (HS), treatment should be based on disease severity, with topical antibiotics for mild disease, oral antibiotics for moderate disease, and biologic agents like adalimumab for severe disease, combined with appropriate surgical interventions when necessary. 1

Treatment Based on Disease Severity

Mild Disease (Hurley Stage I)

• First-line therapy:

  • Topical clindamycin 1% solution - reduces pustules and improves patient self-assessment 2, 1
  • Antiseptic washes (chlorhexidine, benzoyl peroxide, zinc pyrithione) as adjunctive therapy 2, 1
  • Resorcinol 15% cream - reduces pain and duration of abscesses (monitor for irritant dermatitis) 2, 1

• Second-line therapy:

  • Oral tetracyclines (doxycycline 100mg twice daily) for 12 weeks 1
  • Localized surgical intervention for persistent lesions 1

Moderate Disease (Hurley Stage II)

• First-line therapy:

  • Combination therapy with clindamycin 300mg twice daily and rifampin 300mg twice daily for 10-12 weeks 1

• Second-line therapy:

  • Adalimumab if inadequate response to antibiotics 1, 3
    • Dosing: 160 mg initially, 80 mg at week 2, then 40 mg weekly starting at week 4 1, 3
  • Surgical options for persistent lesions 1, 4

Severe Disease (Hurley Stage III)

• First-line therapy:

  • Adalimumab as first-line therapy 1, 3
    • For adults: 160 mg on day 1,80 mg on day 15, then 40 mg weekly or 80 mg every other week 1, 3
    • For adolescents ≥12 years:
      • 30-60 kg: 80 mg on day 1, then 40 mg every other week starting day 8
      • ≥60 kg: 160 mg on day 1,80 mg on day 15, then 40 mg weekly or 80 mg every other week 3

• Second-line therapy:

  • Infliximab 5mg/kg every 8 weeks if adalimumab is ineffective 1
  • Extensive surgical excision 1, 5, 6

Surgical Management

• Indications: Moderate to severe disease, especially with sinus tract formation and scarring 4
• Options based on severity:

  1. Minor procedures:

     • Incision and drainage for acute abscesses (note: high recurrence rates) 1
     • Deroofing procedures for sinus tracts 1

  2. Major procedures:

     • Wide local excision with appropriate reconstruction 5, 6
     • Reconstruction options:
       • Primary closure (note: high recurrence rate of 69.88%) 6
       • Split-thickness skin grafts (lower recurrence rates) 5, 6
       • Local, fasciocutaneous, or musculocutaneous flaps (lower recurrence rates) 5, 6
     • CO₂ laser excision for fibrotic sinus tracts 1

Special Populations

Pregnant Patients

• Cephalexin or azithromycin are safer options for systemic antibiotics 1
• Clindamycin monotherapy may be considered 1

Pediatric Patients

• Doxycycline can be used in patients ≥8 years old 1
• Adalimumab is approved for HS in patients ≥12 years 3

Patients with Comorbidities

• HIV patients: Use doxycycline; avoid rifampin due to potential drug interactions with antiretroviral therapy 1
• Patients with malignancy: Use doxycycline and coordinate biologics with oncology 1

Important Monitoring Considerations

• For adalimumab:

  • Screen for latent tuberculosis before initiating therapy 3
  • Monitor for serious infections during treatment 3
  • Be aware of increased risk of malignancies, especially lymphoma 3

• For antibiotics:

  • Monitor for side effects of clindamycin, particularly severe diarrhea and C. difficile colitis 1
  • Monitor for local skin irritation with topical treatments, especially resorcinol 15% cream 2, 1

Treatment Response Assessment

• Evaluate improvement in number of inflammatory lesions, pain (using Visual Analog Scale), and quality of life measures 1
• Consider alternative or additional therapies if inadequate response after appropriate treatment duration

Common Pitfalls to Avoid

1. Treating HS as simple boils or abscesses with repeated incision and drainage without addressing underlying disease 7
2. Delaying appropriate therapy - early intervention is critical to prevent disease progression 5
3. Using primary closure for extensive disease (high recurrence rates of ~70%) 6
4. Failing to excise all affected tissue during surgical management 6
5. Not considering both inflammatory and fibrotic components of disease 7

Remember that HS is a chronic, relapsing condition that often requires combination therapy targeting both inflammation (medical treatment) and fibrosis (surgical intervention) for optimal outcomes.