What are the treatment options for Hidradenitis Suppurativa (HS) and folliculitis?

Treatment Options for Hidradenitis Suppurativa (HS) and Folliculitis

For hidradenitis suppurativa and folliculitis, the first-line treatment should be doxycycline 100mg twice daily due to its well-established safety profile and demonstrated efficacy in reducing inflammatory lesions. 1

Disease Severity Assessment and Treatment Algorithm

Mild Disease (Hurley Stage I)

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

Moderate Disease (Hurley Stage II)

• First-line options:
  • Combination antibiotic therapy:
    • Clindamycin 300mg orally twice daily with rifampicin 600mg orally once daily for 10-12 weeks
  • Second-line option:
    • Adalimumab if inadequate response to antibiotics 1
  • Surgical options:
    • Deroofing or excision for recurrent nodules and tunnels 2

Severe Disease (Hurley Stage III)

• First-line option:
  • 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 2
  • CO₂ laser excision for fibrotic sinus tracts 2

Laser and Energy-Based Treatments

• Neodymium-doped yttrium-aluminum-garnet (Nd:YAG) laser:

  • Most evidence-supported laser option
  • Settings: 10mm spot size, 10-ms pulse duration, 35-50 J/cm² for skin types I-III; 20-ms pulse duration, 25-40 J/cm² for skin types IV-VI
  • Typically requires 3-4 treatment sessions
  • Target endpoint: delayed post-treatment perifollicular erythema/edema 2

• CO₂ lasers:

  • Used for excision, marsupialization, and vaporization of affected skin
  • Effective for Hurley stage II or III disease 2

• Other energy-based options (less evidence):

  • Long-pulsed alexandrite lasers
  • Diode lasers
  • Intense pulsed light
  • Photodynamic therapy (results with topical sensitizers are equivocal) 2

Special Populations

Pregnant Patients

• Cephalexin or azithromycin are safer options for systemic antibiotics 1

Pediatric Patients

• Patients ≥8 years old can be treated with doxycycline
• For HS in adolescents (12 years and older) requiring biologics:
  • For 30-60kg: Day 1: 80mg adalimumab, Day 8 and subsequent doses: 40mg every other week
  • For ≥60kg: Day 1: 160mg adalimumab, Day 15: 80mg, Day 29 and subsequent: 40mg weekly or 80mg every other week 3

Patients with HIV

• Doxycycline preferred (added benefit of STI prophylaxis)
• Avoid rifampin due to potential drug interactions with antiretroviral therapy 1

Surgical Management

• Incision and drainage should be used only for acute abscesses to relieve pain, not as definitive treatment 2
• Deroofing or excision is recommended for recurrent nodules and tunnels 2
• Wide local excision (using scalpel, CO₂, or electrosurgery) is appropriate for extensive chronic lesions 2
• Wound healing options include:
  • Secondary intention
  • Primary closure
  • Delayed primary closure
  • Flaps, grafts, or skin substitutes 2

Treatment Monitoring

• Evaluate response at 12 weeks using:
  • Lesion count
  • Pain scores
  • Quality of life measures 1
• Monitor for side effects:
  • With clindamycin: severe diarrhea and C. difficile colitis
  • With adalimumab: serious infections including tuberculosis (screen for latent TB before initiating) 1, 3

Important Considerations

• HS is often associated with comorbidities including depression, metabolic syndrome, inflammatory bowel disease, and arthropathies - screen for these conditions 2
• Lifestyle modifications are important adjuncts to treatment:
  • Weight loss if overweight
  • Smoking cessation
  • Wearing loose-fitting clothes 4
• Quality of life is often significantly affected - screen for depression 4

Cautions

• Rifampin should be used with caution due to potential drug interactions and risk of hepatotoxicity 1
• Adalimumab carries risks of serious infections and malignancy (boxed warning) 3
• Avoid doxycycline in breastfeeding patients or limit to 3 weeks without repeating courses 1