What is the treatment for Hidradenitis Suppurativa (HS)?

Treatment of Hidradenitis Suppurativa (HS)

Treatment for hidradenitis suppurativa should follow a stepwise approach based on disease severity, with topical clindamycin for mild disease, oral antibiotics for moderate disease, and adalimumab for severe or refractory cases, alongside appropriate surgical interventions when needed. 1

Disease Classification and Assessment

Before initiating treatment, it's essential to classify HS severity:

• Mild (Hurley I): Localized nodules without sinus tracts or scarring
• Moderate (Hurley II): Recurrent nodules with sinus tract formation and scarring
• Severe (Hurley III): Diffuse involvement with multiple interconnected tracts and scarring

Treatment Algorithm by Disease Severity

Mild Disease (Hurley I)

1. First-line therapy:

   • Topical clindamycin 1% solution/gel twice daily for 12 weeks 2, 1
   • Antiseptic washes as adjunctive therapy 1
   • Resorcinol 15% cream to reduce pain and duration of abscesses 1

2. If inadequate response:

   • Oral tetracyclines (doxycycline 100mg twice daily or tetracycline 500mg twice daily) for 12 weeks 2, 1
   • Consider localized surgical intervention for persistent lesions 1

Moderate Disease (Hurley II)

1. First-line therapy:

   • Clindamycin 300mg orally twice daily with rifampicin 600mg orally once daily for 10-12 weeks 2, 1

2. If inadequate response:

   • Adalimumab (160mg at week 0, 80mg at week 2, then 40mg weekly starting at week 4) 2, 1, 3

Severe Disease (Hurley III)

1. First-line therapy:

   • Adalimumab (160mg at week 0, 80mg at week 2, then 40mg weekly) 2, 1, 3
   • Consider extensive surgical excision 1

2. If inadequate response to adalimumab:

   • Consider infliximab 5mg/kg every 8 weeks 1

Surgical Management

Surgical options should be considered for all patients depending on the type and extent of scarring 2:

• Mild disease: Deroofing of isolated lesions
• Moderate disease: Localized excision with primary closure
• Severe disease: Wide local excision with reconstruction using grafts or flaps 1
• 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

• For patients ≥12 years with moderate-severe HS:
  • Adalimumab is FDA-approved with weight-based dosing 1, 3
  • For 30-60kg: 80mg initially (day 1), then 40mg every other week starting day 8
  • For ≥60kg: 160mg initially (day 1), 80mg at day 15, then 40mg weekly or 80mg every other week starting day 29 3

Patients with Comorbidities

• HIV: Use doxycycline; avoid rifampin due to potential drug interactions 1
• Malignancy: Use doxycycline and coordinate biologics with oncology 1

Monitoring and Follow-Up

• Assess treatment response by improvement in:

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

• When using adalimumab:

  • Screen for latent tuberculosis before initiating therapy
  • Monitor for serious infections during treatment 1, 3

• When using clindamycin:

  • Monitor for severe diarrhea and C. difficile colitis 1

Important Considerations

1. Early treatment is crucial to prevent disease progression and complications 4

2. Combination approach: Both medical (for inflammation) and surgical (for fibrosis) treatments are often necessary 5

3. Maintenance therapy: For patients with good response to adalimumab, therapy should be maintained as long as HS lesions are present 2

4. Wound care: Choose appropriate dressings based on drainage amount, location, and periwound skin condition 1

5. Pain management is an essential component of comprehensive HS care 5