What are the treatment options for hidradenitis suppurativa?

Treatment Options for Hidradenitis Suppurativa

For hidradenitis suppurativa (HS), treatment should be selected based on disease severity, with topical therapies and oral antibiotics for mild disease, combination antibiotics for moderate disease, and biologics like adalimumab for severe disease. 1

Treatment Based on Disease Severity

Mild Disease (Hurley Stage I)

• First-line options:
  • Topical clindamycin 1% solution - reduces pustules and improves patient self-assessment 1
  • Antiseptic washes as adjunctive therapy 1
  • Resorcinol 15% cream - reduces pain and duration of abscesses (monitor for irritant dermatitis) 1, 2
  • Oral tetracyclines (doxycycline 100mg twice daily) for at least 12 weeks 1
• For persistent lesions:
  • Localized surgical intervention 1
  • Intralesional corticosteroid injections 2
  • LAight therapy (combination of intense pulsed light with radiofrequency) - shown to significantly enhance efficacy when combined with topical clindamycin 3

Moderate Disease (Hurley Stage II)

• First-line therapy:
  • Combination of clindamycin and rifampin for 10-12 weeks 1, 4
• Second-line therapy:
  • Adalimumab if inadequate response to antibiotics 1, 5
  • Dosing: 160 mg initially, 80 mg at week 2, then 40 mg weekly starting at week 4 1, 5

Severe Disease (Hurley Stage III)

• First-line therapy:
  • Adalimumab (FDA-approved) 1, 5
  • Dosing for adults: 160 mg on day 1,80 mg on day 15, then 40 mg weekly or 80 mg every other week starting on day 29 5
• Surgical options:
  • Extensive surgical excision with reconstruction using grafts or flaps (lower recurrence rates than primary closure) 1
  • CO₂ laser excision for fibrotic sinus tracts 1

Adalimumab (Humira) - The Only FDA-Approved Biologic for HS

• Dosing for adults:

  • Day 1: 160 mg (given in one day or split over two consecutive days)
  • Day 15: 80 mg
  • Day 29 and subsequent doses: 40 mg weekly or 80 mg every other week 5

• Dosing for adolescents (12 years and older):

  • For 30-60 kg: Day 1: 80 mg; Day 8 and subsequent doses: 40 mg every other week
  • For ≥60 kg: Day 1: 160 mg; Day 15: 80 mg; Day 29 and subsequent doses: 40 mg weekly or 80 mg every other week 5

• Important safety considerations:

  • Monitor for serious infections, including tuberculosis
  • Screen for latent TB before initiating therapy
  • Risk of malignancy, particularly lymphoma 1, 5

Other Biologic Options

• Infliximab: 5mg/kg every 8 weeks can be considered if adalimumab is ineffective 1
• Anakinra: May be considered in refractory cases 6

Special Populations

• Pregnant patients:

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

• Pediatric patients:

  • Doxycycline for patients ≥8 years old
  • Adalimumab approved for patients 12 years and older 1, 5

• Breastfeeding patients:

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

Wound Care

• Choose dressings based on:

  • Drainage amount
  • Location
  • Periwound skin condition
  • Cost and patient preference 1

• Consider negative-pressure therapy for large open wounds (1-4 weeks) followed by delayed reconstruction 1

Common Pitfalls and Caveats

1. Misdiagnosis: HS is often misdiagnosed as simple boils or abscesses, leading to inappropriate treatment 6

2. Delayed treatment: Early intervention is crucial to prevent disease progression and complications 7

3. Inadequate duration of antibiotic therapy: Oral tetracyclines should be administered for at least 12 weeks 1

4. Monotherapy limitations: A comprehensive approach combining medical and surgical interventions is often necessary, as fibrotic lesions generally do not respond to medical treatment alone 6

5. Monitoring complications: Watch for:

   • C. difficile colitis with clindamycin use
   • Serious infections with biologics
   • Local skin irritation with topical treatments 1

6. Treatment resistance: HS often requires long-term maintenance therapy and may need adjustment of treatment strategies over time 4