What are the treatment options for hidradenitis suppurativa?

Treatment Options for Hidradenitis Suppurativa

The first-line treatment for hidradenitis suppurativa (HS) should be determined by disease severity, with topical therapies and oral antibiotics for mild disease (Hurley I), clindamycin plus rifampicin for moderate disease (Hurley II), and adalimumab as first-line therapy for severe disease (Hurley III). 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 1
  • Oral tetracyclines: doxycycline 100mg twice daily for 12 weeks 1
• For persistent lesions: Consider localized surgical intervention 1
• Monitoring: Watch for local skin irritation with topical treatments, especially resorcinol 15% cream 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, 2
• If inadequate response: Adalimumab (160mg at week 0, 80mg at week 2, then 40mg weekly) 1, 3
• Caution: Monitor for severe diarrhea and C. difficile colitis with clindamycin; rifampicin has potential drug interactions, especially with HIV therapies 1

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 reconstruction using grafts or flaps for lower recurrence rates 1
• For fibrotic sinus tracts: CO₂ laser excision 1

Antibiotic Options and Considerations

Antibiotics are valuable in HS management not only for their antimicrobial effects but also for their anti-inflammatory properties 4:

• Tetracyclines: Doxycycline 100mg twice daily is recommended as first-line oral antibiotic for its safety profile and efficacy in reducing inflammatory lesions 1
• Combination therapy: Clindamycin 300mg twice daily + rifampicin 600mg once daily for 10-12 weeks shows superior efficacy compared to clindamycin monotherapy, particularly for moderate-to-severe HS with abscesses, draining fistulae, and ≥5 inflammatory nodules 1, 2
• Alternative antibiotics: Amoxicillin/clavulanic acid, erythromycin, azithromycin, and metronidazole are also treatment options 1

Special Patient Populations

Pregnant Patients

• Preferred antibiotics: Cephalexin or azithromycin are safer options 1
• Avoid: Tetracyclines due to potential fetal harm 1

Pediatric Patients

• For patients ≥12 years: Adalimumab is FDA-approved for moderate to severe HS 3
• For patients ≥8 years: Doxycycline can be used 1
• Dosing considerations: For adalimumab in pediatric patients, weight-based dosing should be followed 3

Breastfeeding Patients

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

Patients with HIV

• Preferred: Doxycycline (provides added STI prophylaxis) 1
• Avoid: Rifampicin due to potential interactions with antiretroviral therapy 1

Patients with Malignancy

• Preferred: Doxycycline 1
• Caution with biologics: Coordinate adalimumab use with oncology due to increased malignancy risk 1, 3

Biologic Therapy with Adalimumab

Adalimumab is the only FDA-approved biologic for HS 3, 5:

• Indication: Moderate to severe HS in patients 12 years and older 3
• Dosing regimen: 160mg at week 0, 80mg at week 2, then 40mg weekly 1, 3
• Important safety considerations:
  • Screen for latent tuberculosis before initiating therapy 1
  • Monitor for serious infections during treatment 1
  • Be aware of potential increased risk of malignancies, including lymphoma 3

Wound Care Management

Proper wound care is crucial, particularly for advanced HS 6:

• Dressing selection: Choose based on drainage amount, location, periwound skin condition, cost, and patient preference 1
• For large open wounds: Consider negative-pressure therapy for 1-4 weeks followed by delayed reconstruction 1

Treatment Response Evaluation

• Evaluate response at 12 weeks using measures such as lesion count, pain scores, and quality of life 1
• For patients without evidence of clinical improvement, consider switching to alternative therapies 1

Prognostic Factors

• Poor response predictors: High BMI and smoking habits appear to be predictive factors of poor response to antibiotic therapy 2
• Treatment challenge: The chronic, recurrent nature of HS often requires maintenance therapy and a combined medical-surgical approach 7, 4