What are the treatment options for hidradenitis suppurativa?

Treatment Options for Hidradenitis Suppurativa

For 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 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 orally twice daily with rifampicin 600mg orally once daily for 10-12 weeks 1
  • Monitor for severe diarrhea and C. difficile colitis with clindamycin
  • Use rifampin with caution due to potential drug interactions, especially with HIV therapies
• Second-line therapy (if inadequate response):
  • Adalimumab (see dosing below) 1, 2

Severe Disease (Hurley Stage III)

• First-line therapy:
  • Adalimumab (160mg at week 0, 80mg at week 2, then 40mg weekly) 1, 2
  • Screen for latent TB before initiating therapy
  • Monitor for serious infections during treatment
• Surgical options:
  • Extensive surgical excision 1, 3

Adalimumab Dosing for HS

• Adults:

  • Day 1: 160mg (given in one day or split over two consecutive days)
  • Day 15: 80mg
  • Day 29 and subsequent doses: 40mg weekly or 80mg every other week 2

• Adolescents 12 years and older:

  • For 30-60kg: Day 1: 80mg; Day 8 and subsequent doses: 40mg every other week
  • For ≥60kg: Day 1: 160mg; Day 15: 80mg; Day 29 and subsequent doses: 40mg weekly or 80mg every other week 2

Surgical Management

• Consider surgical options for all patients depending on type and extent of scarring 1
• Radical excision is important for preventing recurrence, especially for persistent or extensive disease 3
• Reconstruction options based on defect size and location:
  • Primary closure
  • Fasciocutaneous flaps
  • Split-thickness skin grafts 3
• CO₂ laser excision for fibrotic sinus tracts 1
• Important note: Complications and recurrences are mostly related to the location of the disease, with higher rates in perineal, perianal, and buttocks sites 3

Special Populations

• Pregnant patients:
  • Cephalexin or azithromycin are safer options for systemic antibiotics 1
• Breastfeeding patients:
  • Avoid doxycycline or limit to 3 weeks without repeating courses 1
• Pediatric patients:
  • Doxycycline can be used in children ≥8 years old 1
• HIV patients:
  • Doxycycline preferred (added benefit of STI prophylaxis)
  • Avoid rifampin due to potential drug interactions with antiretroviral therapy 1

Pain Management

• Pain is one of the most debilitating symptoms of HS but even the highest-rated pain management modalities are considered only moderately effective by patients 4
• Topical options:
  • Diclofenac gel 1% (first-line)
  • Liposomal xylocaine 4% and 5% cream/ointment (first-line, quick acting but limited duration) 5
• Compounded topical preparations may extend duration of effect 5

Follow-up and Monitoring

• Evaluate response at 12 weeks using:
  • Lesion count
  • Pain scores
  • Quality of life measures 1
• Monitor for adalimumab side effects:
  • Serious infections, including tuberculosis
  • Malignancy risk 2

Treatment Approach Summary

A comprehensive approach with medical therapy and surgery is recommended based on disease severity, with careful attention to pain management and wound care to improve quality of life 6, 7. The evidence strongly supports antibiotics for mild-moderate disease and adalimumab for moderate-severe disease, with surgery playing a critical role for persistent or extensive lesions 1, 2, 3.