What are the treatment options for Hidradenitis suppurativa?

Treatment Options for Hidradenitis Suppurativa

The most effective treatment approach for hidradenitis suppurativa (HS) follows a severity-based algorithm, with first-line therapy being doxycycline 100mg twice daily for mild disease, clindamycin-rifampin combination for moderate disease, and adalimumab for severe disease. 1

Disease Severity Classification and Treatment Algorithm

Mild Disease (Hurley Stage I)

• First-line options:
  • Topical therapies:
    • Clindamycin 1% solution
    • Antiseptic washes
    • Resorcinol 15% cream (monitor for local skin irritation)
  • Systemic therapy: Doxycycline 100mg twice daily for 12 weeks 1
• For persistent lesions: Localized surgical intervention

Moderate Disease (Hurley Stage II)

• First-line therapy: Clindamycin 300mg twice daily + Rifampin 600mg once daily for 10-12 weeks 1
• Second-line therapy: Adalimumab if inadequate response to antibiotics 1, 2

Severe Disease (Hurley Stage III)

• First-line therapy: Adalimumab (160mg at week 0, 80mg at week 2, then 40mg weekly) 1, 2
• Surgical options: Extensive surgical excision with reconstruction using grafts or flaps 1, 3

Antibiotic Options in Detail

Antibiotics serve dual purposes in HS treatment - both antimicrobial and anti-inflammatory effects 4:

• Tetracyclines:

  • Doxycycline 100mg twice daily (first-line for mild disease)
  • Added benefit of prophylaxis against bacterial STIs in high-risk patients 1
  • Can be used in patients ≥8 years old
  • Avoid in pregnancy or limit to 3 weeks in breastfeeding patients

• Clindamycin-Rifampin combination:

  • Clindamycin 300mg twice daily + Rifampin 600mg once daily for 10-12 weeks
  • Monitor for severe diarrhea and C. difficile colitis with clindamycin
  • Use rifampin with caution in patients on HIV therapy due to drug interactions 1

• Alternative antibiotics:

  • Amoxicillin/clavulanic acid
  • Erythromycin
  • Azithromycin (safer option for pregnant patients)
  • Metronidazole
  • Cephalexin (safer option for pregnant patients) 1

Biologic Therapy

Adalimumab is FDA-approved for moderate to severe HS in patients 12 years and older 2:

• Dosing regimen: 160mg at week 0 (given in one day or split over two days), 80mg at week 2, then 40mg weekly starting at week 4 1, 2
• Important monitoring:
  • Screen for latent tuberculosis before initiating therapy
  • Monitor for serious infections during treatment
  • Be aware of potential risk for malignancies, including lymphoma 2
• Evaluate response at 12 weeks using lesion count, pain scores, and quality of life measures 1

Surgical Management

Surgical options should be considered for all patients depending on the type and extent of scarring 1, 3:

• For localized lesions: Incision and drainage (temporary relief only)
• For recurrent cases: Wide surgical excision with:
  • Primary closure (higher recurrence rates)
  • Reconstruction using grafts or flaps (lower recurrence rates) 3
• For fibrotic sinus tracts: CO₂ laser excision 1
• For large open wounds: Consider negative-pressure therapy for 1-4 weeks followed by delayed reconstruction 1

Special Considerations

• Wound care: Choose dressings based on drainage amount, location, periwound skin condition, cost, and patient preference 1, 5
• Pregnant patients: Use cephalexin or azithromycin for systemic antibiotics 1
• Pediatric patients: Adalimumab is approved for HS in patients ≥12 years; doxycycline can be used in patients ≥8 years 1, 2
• HIV patients: Prefer doxycycline; avoid rifampin due to potential drug interactions with antiretroviral therapy 1
• Patients with malignancy: Use doxycycline and coordinate biologic therapy with oncology 1

Treatment Pitfalls to Avoid

• Don't delay appropriate treatment: Early intervention may reduce complications and disease progression 6
• Don't rely solely on antibiotics for moderate-to-severe disease: Biologics like adalimumab should be considered early for Hurley stage III disease 1, 6
• Don't overlook surgical options: Surgical intervention is often necessary for definitive treatment of persistent or recurrent lesions 1, 3
• Don't forget to eliminate acute inflammation before major surgery: Use antibiotics and minor procedures like abscess drainage to stabilize acute phase before wide surgical excision 3
• Don't underestimate the importance of wound care: Proper wound care is essential, particularly in advanced HS 5