What is the treatment for hidradenitis?

Treatment of Hidradenitis Suppurativa

For hidradenitis suppurativa (HS), treatment should be based on disease severity using the Hurley staging system, with topical clindamycin for mild disease, clindamycin-rifampin combination for moderate disease, and adalimumab for severe disease as first-line therapies. 1

Treatment Algorithm Based on Disease Severity

Mild Disease (Hurley Stage I)

• First-line therapy:

  • Topical clindamycin 1% solution/gel twice daily for 12 weeks 1
  • Antiseptic washes (chlorhexidine, zinc pyrithione) 2
  • Resorcinol 15% cream (monitor for contact dermatitis) 2, 1

• For acute flares:

  • Intralesional corticosteroid injections for inflamed lesions 2
  • Warm compresses 2
  • Incision and drainage for painful fluctuant lesions 2

• If inadequate response:

  • Oral tetracyclines (doxycycline 100mg twice daily) for 12 weeks 1

Moderate Disease (Hurley Stage II)

• First-line therapy:

  • Clindamycin 300mg orally twice daily with rifampicin 600mg orally once daily for 10-12 weeks 1
  • Caution: Monitor for severe diarrhea and C. difficile colitis with clindamycin 1

• If inadequate response:

  • Adalimumab (160mg at week 0, 80mg at week 2, then 40mg weekly) 1
  • Caution: Screen for tuberculosis before initiating therapy 1

• Surgical options:

  • Deroofing of sinus tracts 2
  • CO₂ laser excision for fibrotic sinus tracts 1

Severe Disease (Hurley Stage III)

• First-line therapy:

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

• If adalimumab ineffective:

  • Infliximab 5mg/kg every 8 weeks 1

• Surgical management:

  • Extensive surgical excision with reconstruction using grafts or flaps 1, 3
  • Note: Wide surgical excision has shown lower recurrence rates (18.75%) compared to more conservative approaches 3

Special Considerations

Pain Management

• Pain is a debilitating symptom of HS that requires specific attention 4
• Use appropriate analgesics based on pain severity
• Consider both acute and chronic pain components

Pediatric Patients

• Similar treatment approach as adults with some modifications 5
• Doxycycline can be used in children ≥8 years old 1
• Evaluate for metabolic syndrome and precocious puberty 2

Pregnant Patients

• Prioritize topical treatments and procedural interventions 2
• Cephalexin or azithromycin are safer options for systemic antibiotics 1
• Avoid retinoids and hormonal therapies (contraindicated) 2

Monitoring Treatment Response

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

Common Pitfalls to Avoid

1. Misdiagnosis: HS is often misdiagnosed as simple boils or abscesses, leading to inappropriate treatment 6
2. Inadequate surgical margins: When performing surgery, inadequate excision margins increase recurrence risk 3
3. Neglecting wound care: Proper dressing selection based on drainage amount, location, and periwound skin condition is essential 1
4. Overlooking comorbidities: HS is associated with metabolic syndrome and other inflammatory conditions that may require additional management 2
5. Treating only acute flares: HS requires long-term management strategies to prevent recurrence and disease progression 7

The treatment of HS has evolved significantly with better understanding of its pathogenesis. A comprehensive approach targeting both inflammation (with medical therapy) and fibrosis (with surgical intervention) is necessary for optimal management 6.