What are the treatment options for hidradenitis suppurativa?

Treatment Options for Hidradenitis Suppurativa

The treatment of hidradenitis suppurativa (HS) should follow a structured approach based on disease severity, with first-line options including topical clindamycin, oral antibiotics, and adalimumab for moderate to severe cases. 1

Disease Severity and Treatment Algorithm

Mild Disease (Hurley Stage I)

• First-line therapy:

  • Antiseptic washes (chlorhexidine or zinc pyrithione) 1
  • Topical clindamycin 1% solution/gel twice daily for 12 weeks 1
  • Lifestyle modifications (weight loss, smoking cessation)

• For acute flares:

  • Intralesional corticosteroid injections
  • Warm compresses
  • Incision and drainage for painful fluctuant lesions 1

Moderate Disease (Hurley Stage II)

• First-line therapy:

  • Oral doxycycline 100mg twice daily 1
  • Clindamycin 300mg orally twice daily with rifampicin 600mg orally once daily for 10-12 weeks 1

• Second-line therapy:

  • Adalimumab (160mg at week 0, 80mg at week 2, then 40mg weekly) 1, 2
  • Localized surgical intervention for persistent lesions 1

Severe Disease (Hurley Stage III)

• First-line therapy:

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

• Second-line therapy:

  • Infliximab 5mg/kg every 8 weeks if adalimumab is ineffective 1
  • Extensive surgical excision 1, 3

Surgical Management

Surgical options are crucial for managing HS, particularly for recurrent or advanced cases:

• Minor procedures:

  • Incision and drainage for acute painful lesions
  • Deroofing of sinus tracts

• Major procedures:

  • Wide surgical excision with appropriate reconstruction 3
  • CO₂ laser excision for fibrotic sinus tracts 1
  • Reconstruction using grafts or flaps (lower recurrence rates than primary closure) 1

Surgical intervention should be considered for all patients depending on the type and extent of scarring 1. Complete removal of affected tissue is essential, as residual disease leads to recurrence 3.

Special Considerations

Medication Safety

• When using adalimumab:
  • Screen for latent TB before initiating therapy
  • Monitor for serious infections
  • Be aware of potential malignancy risk, especially lymphoma 2

Special Populations

• Pregnant patients:

  • Cephalexin or azithromycin are safer options for systemic antibiotics 1

• Pediatric patients:

  • Adalimumab is indicated for moderate to severe HS in patients 12 years and older 2
  • Patients ≥8 years old can be treated with doxycycline 1

• Breastfeeding patients:

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

• Patients with HIV:

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

Monitoring Treatment Response

• Assess improvement in:

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

• Monitor for side effects:

  • Local skin irritation with topical treatments
  • Diarrhea and C. difficile colitis with clindamycin
  • Infections and malignancy with biologics 1, 2

Common Pitfalls to Avoid

1. Misdiagnosis as simple boils or abscesses, leading to inadequate treatment 4
2. Delayed treatment - early intervention is crucial to prevent disease progression and complications 5
3. Focusing only on acute management without addressing chronic disease control
4. Inadequate surgical margins when performing excision, leading to recurrence 3
5. Failure to address both inflammatory and fibrotic components of the disease 4

The management of HS requires a comprehensive approach combining medical therapy for inflammation and surgical intervention for fibrotic tissue, with treatment selection guided by disease severity and individual patient factors 6, 7.