What are the treatment options for hidradenitis suppurativa?

Treatment Options for Hidradenitis Suppurativa

Adalimumab is the recommended first-line therapy for moderate to severe hidradenitis suppurativa (HS), with topical clindamycin and oral tetracyclines recommended for mild disease. 1

Treatment Algorithm Based on Disease Severity

Mild Disease (Hurley Stage I)

• First-line options:

  • Topical clindamycin 1% solution - reduces pustules and improves patient self-assessment 1
  • Oral tetracyclines (doxycycline 100mg twice daily or lymecycline) for at least 12 weeks 1
  • Adjunctive antiseptic washes 1
  • Resorcinol 15% cream - reduces pain and duration of abscesses (monitor for irritant dermatitis) 1

• For persistent lesions:

  • Localized surgical intervention 1

Moderate Disease (Hurley Stage II)

• First-line options:

  • Clindamycin + Rifampin combination for 10-12 weeks 1

• If inadequate response:

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

Severe Disease (Hurley Stage III)

• First-line therapy:

  • Adalimumab with dosing as above 1, 2
  • Consider extensive surgical excision 1, 3

• If adalimumab is ineffective:

  • Infliximab 5mg/kg every 8 weeks 1

Surgical Management Options

• Surgical approaches based on disease severity:

  • Incision and drainage - for acute painful abscesses (note: high recurrence rate) 1, 3
  • Deroofing procedures - for recurrent lesions 1, 3
  • Wide local excision - for extensive disease 1, 3
  • CO₂ laser excision - effective for fibrotic sinus tracts 1

• Reconstruction considerations:

  • Grafts or flaps show lower recurrence rates than primary closure 1, 3
  • Negative-pressure therapy can be considered for large open wounds (1-4 weeks) followed by delayed reconstruction 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
• For HS in adolescents (12 years and older), adalimumab dosing is weight-based:
  • 30-60kg: 80mg on day 1, then 40mg every other week starting on day 8 1, 2
  • ≥60kg: 160mg on day 1 (or split over two days), 80mg on day 15, then 40mg weekly or 80mg every other week starting on day 29 1, 2

Breastfeeding Patients

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

Patients with HIV

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

Patients with Malignancy

• Use doxycycline and coordinate biologics with oncology 1

Pain Management

• Topical diclofenac gel 1% is considered first-line for topical pain control 4
• Liposomal xylocaine 4% or 5% cream/ointment provides immediate but short-duration (1-2 hours) relief 4
• Warm compresses are commonly used by patients, though marijuana products and opioids are rated as most effective by patients for pain control 5

Important Monitoring Considerations

Treatment Response Monitoring

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

Safety Monitoring

• For adalimumab:

  • Screen for latent TB before initiating therapy
  • Monitor for serious infections during treatment 1, 2
  • Be aware of the boxed warning for serious infections and malignancy risk 2

• For antibiotics:

  • Monitor for severe diarrhea and C. difficile colitis with clindamycin 1

Common Pitfalls and Caveats

• HS is often misdiagnosed as simple boils or abscesses, leading to inadequate treatment 6
• Fibrotic lesions generally do not respond to medical therapy and require surgical intervention 6
• Even the highest-rated pain management modalities are considered only moderately effective by patients 5
• Incision and drainage alone has a high recurrence rate and should not be considered definitive treatment 1, 3
• Comprehensive treatment requires addressing both inflammation (medical therapy) and fibrosis (surgical intervention) 6