What are the treatment options for hidradenitis suppurativa?

Hidradenitis Suppurativa Treatment Options

The first-line treatment for hidradenitis suppurativa should be based on disease severity, with topical therapies and tetracyclines for mild disease (Hurley I), clindamycin plus rifampin for moderate disease (Hurley II), and adalimumab as first-line therapy for severe disease (Hurley III). 1

Treatment Algorithm Based on Disease Severity

Mild Disease (Hurley Stage I)

• First-line options:
  • Topical clindamycin 1% solution applied twice daily 1, 2
  • Antiseptic washes
  • Resorcinol 15% cream (monitor for local skin irritation) 1, 2
  • Oral tetracyclines (doxycycline 100mg twice daily) for 12 weeks 1
• For persistent lesions:
  • Localized surgical intervention
  • Intralesional corticosteroid injections 2

Moderate Disease (Hurley Stage II)

• First-line therapy:
  • Clindamycin 300mg orally twice daily with rifampin 600mg orally once daily for 10-12 weeks 1
• If inadequate response:
  • Adalimumab (160mg at week 0, 80mg at week 2, then 40mg weekly) 1, 3
• Adjunctive options:
  • Device-based therapies such as LAight therapy (combining intense pulsed light with radiofrequency) 2

Severe Disease (Hurley Stage III)

• First-line therapy:
  • Adalimumab (160mg at week 0, 80mg at week 2, then 40mg weekly) 1, 3
• Surgical options:
  • Extensive surgical excision with appropriate reconstruction 1, 4

Antibiotic Options

Antibiotics play a crucial role in HS management, particularly for mild to moderate disease:

• First-line oral antibiotics:

  • Doxycycline 100mg twice daily (preferred first-line) 1
  • Clindamycin 300mg twice daily + rifampin 600mg once daily (10-12 weeks) 1, 5

• Alternative antibiotics:

  • Rifampin (use with caution due to potential drug interactions)
  • Amoxicillin/clavulanic acid
  • Erythromycin
  • Azithromycin
  • Metronidazole 1, 5

Biologic Therapy

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

• Adalimumab (FDA-approved for HS):

  • Adults: Initial dose of 160mg (day 1), 80mg (day 15), then 40mg weekly starting day 29 1, 3
  • Adolescents (12+ years):
    • 30-60kg: 80mg (day 1), then 40mg every other week starting day 8
    • ≥60kg: 160mg (day 1), 80mg (day 15), then 40mg weekly or 80mg every other week starting day 29 3

• Important safety considerations:

  • Screen for latent tuberculosis before initiating therapy
  • Monitor for serious infections during treatment
  • Be aware of increased malignancy risk, especially lymphoma 3

Surgical Management

Surgical intervention is an important component of HS management:

• Indications for surgery:

  • Persistent individual lesions despite medical therapy
  • Extensive scarring and sinus tract formation
  • Severe disease (Hurley III) 1, 4

• Surgical options:

  • Incision and drainage (temporary relief only)
  • Local excision of individual lesions
  • Wide surgical excision (lowest recurrence rate: 18.75%) 4
  • CO₂ laser excision for fibrotic sinus tracts 1

• Reconstruction methods:

  • Primary closure (higher recurrence rate)
  • Skin grafts or flaps (lower recurrence rate)
  • Healing by secondary intention 1, 4

Special Populations

• Pregnant patients:

  • Cephalexin or azithromycin are safer options for systemic antibiotics 1
  • Avoid adalimumab during pregnancy

• Pediatric patients:

  • Children ≥8 years can be treated with doxycycline
  • Adolescents ≥12 years can receive adalimumab with weight-based dosing 1, 3

• Breastfeeding patients:

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

Treatment Evaluation

• Evaluate response at 12 weeks using:

  • Lesion count
  • Pain scores
  • Quality of life measures 1

• For adalimumab therapy, discontinue if no response is observed after 12 weeks 3, 6

Common Pitfalls to Avoid

1. Relying solely on antibiotics without considering surgical options - Both approaches are often needed for optimal management 4, 5

2. Inadequate duration of antibiotic therapy - Most regimens require 10-12 weeks for optimal effect 1

3. Overlooking potential drug interactions - Particularly with rifampin in patients on other medications 1

4. Failing to screen for TB before starting biologics - Essential before initiating adalimumab 3

5. Treating all disease stages with the same approach - Treatment must be tailored to disease severity 1, 6