What are the treatment options for hidradenitis suppurativa?

Treatment Options for Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) treatment should be based on disease severity, with topical therapies and tetracyclines for mild disease, clindamycin-rifampin combination for moderate disease, and adalimumab as first-line therapy 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
  • Doxycycline 100mg twice daily for 12 weeks 1
• Adjunctive treatments:
  • Localized surgical intervention for persistent lesions
  • Pain management with topical diclofenac 1% gel or liposomal xylocaine 4-5% 2

Moderate Disease (Hurley Stage II)

• First-line options:
  • Clindamycin 300mg orally twice daily with rifampicin 600mg orally once daily for 10-12 weeks 1
• Second-line options:
  • Adalimumab if inadequate response to antibiotics 1, 3
  • Surgical excision for persistent lesions 4

Severe Disease (Hurley Stage III)

• First-line therapy:
  • Adalimumab (160mg at week 0, 80mg at week 2, then 40mg weekly) 1, 3
• Adjunctive treatment:
  • Extensive surgical excision 1, 4
  • Pain management (may require multiple modalities) 5

Antibiotic Options

Antibiotics serve as a cornerstone of HS treatment, particularly for mild to moderate disease:

• Tetracyclines:

  • Doxycycline 100mg twice daily (first-line oral antibiotic) 1
  • Added benefit of prophylaxis against bacterial STIs
  • Avoid in children under 8 years, pregnant women, or limit to 3 weeks in breastfeeding women

• Clindamycin-Rifampin Combination:

  • Clindamycin 300mg twice daily + rifampin 600mg once daily for 10-12 weeks 1
  • Monitor for GI side effects, particularly severe diarrhea and C. difficile colitis
  • Use rifampin with caution in patients with HIV due to potential drug interactions

• Other antibiotic options:

  • Amoxicillin/clavulanic acid
  • Erythromycin
  • Azithromycin
  • Metronidazole 1

Biologic Therapy

For moderate to severe HS, biologics have shown significant efficacy:

• Adalimumab (Humira):
  • FDA-approved for moderate to severe HS 3
  • Adult dosing: 160mg on day 1 (given in one day or split over two consecutive days), 80mg on day 15, then 40mg weekly or 80mg every other week 1, 3
  • Adolescent dosing (12+ years):
    • 30-60kg: 80mg on day 1, then 40mg every other week starting day 8
    • ≥60kg: 160mg on day 1 (or split over two days), 80mg on day 15, then 40mg weekly or 80mg every other week 3
  • Important safety monitoring:
    • Screen for latent TB before initiating therapy
    • Monitor for serious infections during treatment
    • Be aware of increased malignancy risk 3

Surgical Options

Surgery plays a crucial role in HS management, especially for fibrotic lesions that don't respond to medical therapy:

• Localized procedures:

  • Minor excision for isolated lesions
  • CO₂ laser excision for fibrotic sinus tracts 1

• Extensive surgical excision:

  • Recommended for severe, recurrent cases 1, 4
  • Reconstruction options include primary closure, fasciocutaneous flaps, or split-thickness skin grafts
  • Lower recurrence rates with grafts/flaps compared to primary closure 4
  • Complications occur most frequently in perineal, perianal, and buttocks sites 4

Pain Management

Pain is one of the most debilitating aspects of HS and requires specific attention:

• Topical options:

  • Diclofenac gel 1% (first-line) 2
  • Liposomal xylocaine 4-5% (quick-acting but short duration) 2
  • Warm compresses (most commonly used by patients) 5

• Systemic options:

  • NSAIDs (ibuprofen/naproxen)
  • Opioids for severe pain 5

Special Populations

• Pregnant patients:

  • Cephalexin or azithromycin for systemic antibiotics 1
  • Avoid doxycycline and adalimumab

• Pediatric patients:

  • Doxycycline can be used in children ≥8 years old 1
  • Adalimumab approved for adolescents 12+ years 3

• HIV patients:

  • Prefer doxycycline for added STI prophylaxis
  • Avoid rifampin due to potential interactions with antiretroviral therapy 1

Follow-up and Monitoring

• Evaluate treatment response at 12 weeks using lesion count, pain scores, and quality of life measures 1
• Monitor for medication side effects:
  • Skin irritation with topical therapies
  • Diarrhea with clindamycin
  • Serious infections with adalimumab 1, 3

Common Pitfalls

• Misdiagnosis: HS is often misdiagnosed as simple boils or abscesses, leading to inappropriate treatment 6
• Delayed treatment: Early and wide surgical excision is important to prevent complications and recurrence 4
• Inadequate pain control: Even the highest-rated pain management modalities are considered only moderately effective by patients 5
• Single-modality approach: A comprehensive approach with adjuvant therapy, medical therapy, and surgery is recommended 6