How to treat Hidradenitis suppurativa?

Treatment of Hidradenitis Suppurativa

For hidradenitis suppurativa (HS), treatment should be based on disease severity with topical clindamycin 1% solution as first-line for mild disease, oral tetracyclines for moderate disease, and adalimumab for severe disease. 1

Treatment Algorithm Based on Disease Severity

Mild Disease (Hurley Stage I)

• First-line therapy:
  • Topical clindamycin 1% solution twice daily 1
  • Antiseptic washes as adjunctive therapy
  • Resorcinol 15% cream for pain and abscess duration reduction (monitor for irritant dermatitis) 1
• If inadequate response:
  • Oral doxycycline 100mg twice daily for at least 12 weeks 1
• For persistent localized lesions:
  • Consider localized surgical intervention 1, 2

Moderate Disease (Hurley Stage II)

• First-line therapy:
  • Oral tetracyclines (doxycycline 100mg twice daily or lymecycline) for at least 12 weeks 1
• If inadequate response:
  • Combination therapy with clindamycin and rifampin for 10-12 weeks 1, 3
  • Clindamycin 300mg twice daily + rifampin 600mg daily has shown significant improvement in disease severity 3
• If still inadequate response:
  • Adalimumab (see dosing below) 1, 4

Severe Disease (Hurley Stage III)

• First-line therapy:
  • Adalimumab: 160mg initially, 80mg at week 2, then 40mg weekly starting at week 4 1, 4
  • FDA approved for moderate to severe HS in patients 12 years and older 4
• If adalimumab ineffective:
  • Consider infliximab 5mg/kg every 8 weeks 1
• Surgical management:
  • Extensive surgical excision for recurrent or persistent cases 1, 2

Surgical Options

• For persistent lesions despite medical therapy:
  • Incision and drainage (temporary relief only)
  • Deroofing procedures for recurrent lesions
  • Wide local excision for extensive disease 1, 2
  • CO₂ laser excision for fibrotic sinus tracts 1
• Reconstruction options:
  • Grafts or flaps show lower recurrence rates than primary closure 1, 2
  • Consider negative-pressure therapy for large open wounds (1-4 weeks) before delayed reconstruction 1

Special Populations Considerations

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 patients 12 years and older 4

Breastfeeding Patients

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

Patients with HIV

• Doxycycline preferred (added benefit of STI prophylaxis)
• Avoid rifampin due to potential drug interactions with antiretroviral therapy 1

Patients with Malignancy

• Use doxycycline and coordinate biologics with oncology 1
• Important safety concern: Monitor for serious infections, lymphoma and other malignancies with TNF blockers like adalimumab 4

Wound Care

• Choose dressings based on drainage amount, location, periwound skin condition 1, 5
• Antiseptic washes are generally recommended 1, 5

Monitoring Treatment Response

• Assess improvement in:
  • Number of inflammatory lesions
  • Pain (using Visual Analog Scale)
  • Quality of life measures 1

Important Cautions

• For adalimumab therapy:
  • Screen for latent TB before initiating therapy
  • Monitor for serious infections
  • Be aware of potential risk for lymphoma and other malignancies, especially in adolescent and young adult males when combined with immunosuppressants 1, 4
• For clindamycin:
  • Monitor for severe diarrhea and C. difficile colitis 1
• For resorcinol cream:
  • Monitor for local skin irritation 1

Proper management of HS requires addressing both inflammatory and fibrotic components of the disease. While medical therapy targets inflammation, surgical intervention is often necessary for fibrotic lesions that don't respond to medical treatment 6.