What is the treatment for Hidradenitis Suppurativa (HS)?

Treatment for Hidradenitis Suppurativa

The treatment of hidradenitis suppurativa (HS) should be based on disease severity using the Hurley staging system, with a stepwise approach from topical antibiotics for mild disease to biologics and surgery for moderate-to-severe disease. 1, 2

Disease Assessment

• HS severity should be evaluated using the Hurley staging system, which classifies patients into three stages based on the presence of abscesses, sinus tracts, and scarring 2
• The Hidradenitis Suppurativa Clinical Response (HiSCR) is a more dynamic tool for assessing treatment response, especially in clinical trials 2
• Patient-reported outcomes including pain (Visual Analog Scale) and quality of life (Dermatology Life Quality Index) should be monitored 2

Treatment Algorithm Based on Disease Severity

Mild Disease (Hurley Stage I/mild Stage II)

• First-line therapy: Topical clindamycin 1% solution/gel twice daily for 12 weeks 1, 3
• Alternative first-line: Tetracycline 500 mg twice daily for up to 4 months for more widespread mild disease 1, 3
• If no response after 3 months, escalate to second-line therapy 3

Moderate Disease (Hurley Stage II)

• Second-line therapy: Clindamycin 300 mg twice daily with rifampicin 600 mg once daily (or 300 mg twice daily) for 10 weeks 1, 3
• Weight loss should be encouraged as an adjunctive therapy for patients with obesity 1
• Consider surgical procedures such as deroofing for recurrent nodules and tunnels 1, 3

Moderate-to-Severe Disease (Hurley Stage II/III)

• Third-line therapy: Adalimumab (FDA-approved for moderate-to-severe HS) 4
  • Loading dose: 160 mg at week 0,80 mg at week 2
  • Maintenance: 40 mg weekly starting from week 4 3, 4
• For adolescents 12 years and older weighing ≥60 kg: Same dosing as adults 4
• For adolescents 30-60 kg: 80 mg on day 1, then 40 mg every other week starting day 8 4

Severe Disease (Hurley Stage III)

• Surgical intervention: Wide local excision for extensive chronic lesions and scarring 1, 5
• Continue adalimumab therapy to manage inflammation before and after surgery 3, 6
• Negative pressure wound therapy may be beneficial for wound healing after surgery 3

Special Considerations

• Children and adolescents: Treatment recommendations are based on case reports and extrapolation from adult data 3

  • Finasteride may be considered in early-onset HS, especially with endocrine comorbidities 3
  • Adalimumab is approved for HS in patients 12 years and older 4

• Adjunctive therapies should be offered to all patients 3:

  • Pain management
  • Weight loss for patients with obesity
  • Tobacco cessation
  • Treatment of superinfections
  • Appropriate wound dressings

Monitoring and Follow-up

• Assess treatment response using HiSCR, which measures reduction in inflammatory lesions 3, 2
• Monitor for adverse effects, especially with biologics (serious infections, malignancy) 4
• Evaluate quality of life improvement using DLQI 3, 2

Treatment Pitfalls to Avoid

• Delaying escalation of therapy when first-line treatments fail can lead to disease progression and irreversible scarring 6, 7
• Failing to address modifiable risk factors like obesity and smoking 1
• Not considering surgical options for recurrent nodules and sinus tracts 5
• Overlooking comorbidities such as metabolic syndrome, inflammatory arthritis, and inflammatory bowel disease 6

The treatment approach should aim for early intervention to prevent irreversible skin damage, adequate control of symptoms including pain, and management of extra-cutaneous comorbidities 6, 7.