What are the treatment options for hidradenitis suppurativa?

Treatment Options for Hidradenitis Suppurativa

Treatment of hidradenitis suppurativa (HS) requires a stepwise approach based on disease severity, with options ranging from topical therapies to biologics and surgery, with adalimumab being the only FDA-approved biologic for moderate-to-severe disease. 1

Initial Assessment and Classification

• HS is characterized by painful, deep-seated nodules, abscesses, and draining tunnels in axillary, inguinal, genitoanal, or inframammary areas 2
• Classify disease severity using Hurley staging (I-mild, II-moderate, III-severe) to guide treatment selection 3
• Measure pain (using VAS), quality of life (using DLQI), and count inflammatory lesions to establish baseline and monitor treatment response 3

First-Line Treatments

Topical Therapies

• Clindamycin 1% solution for mild disease (Hurley stage I-II) - reduces pustules but has limited effect on inflammatory nodules 3
• Antiseptic washes (chlorhexidine, benzoyl peroxide, zinc pyrithione) can be used as adjunctive therapy 3
• Resorcinol 15% cream can reduce pain and duration of abscesses in mild disease 3

Systemic Antibiotics

• Oral tetracyclines (doxycycline 100mg or lymecycline 408mg once or twice daily) for 12 weeks as first-line therapy 3
• For inadequate response, combination therapy with clindamycin 300mg and rifampicin 300mg twice daily for 10-12 weeks 3
• Consider treatment breaks to assess ongoing need and limit antimicrobial resistance 3

Second-Line Treatments

Anti-Androgens and Metabolic Agents

• Metformin - particularly useful in patients with concomitant insulin resistance 3
• Spironolactone - for female patients with hormonal influence on disease 3
• Finasteride - can be considered in select cases, particularly in male patients 3
• Combined oral contraceptives - option for female patients 3

Retinoids

• Acitretin (0.3-0.5 mg/kg/day) - consider in males and non-fertile females unresponsive to antibiotics 3
• Oral isotretinoin - not recommended unless there are concomitant moderate-to-severe acneiform lesions 3

Other Systemic Options

• Dapsone - consider in patients unresponsive to antibiotic therapies 3
• Intralesional corticosteroid injections (triamcinolone 10mg/mL) - for acute, localized flares 3
• Systemic prednisone - for acute, widespread flares 3

Biologics for Moderate-to-Severe Disease

FDA-Approved Biologic

• Adalimumab (Humira) - the only FDA-approved biologic for moderate-to-severe HS in patients 12 years and older 1
  • Adult dosing: 160mg on Day 1 (given in one day or split over two consecutive days), 80mg on Day 15, then 40mg weekly starting on Day 29 1
  • Adolescent dosing (12+ years): Weight-based dosing starting with loading doses 1

Other Biologics

• Infliximab (5mg/kg every 8 weeks) - consider in patients unresponsive to adalimumab 3
• Secukinumab - emerging evidence supports use in moderate-to-severe disease 3, 4
• Ustekinumab - may be considered based on limited evidence 3, 4

Surgical Interventions

• Incision and drainage - only for acute abscesses to relieve pain, not recommended as definitive treatment 3
• Deroofing or excision - for recurrent nodules and tunnels 3
• Wide local excision - appropriate for extensive chronic lesions (Hurley stage III) 3
• Consider surgical referral when medical therapy fails 3

Lifestyle Modifications

• Smoking cessation - strongly recommended as smoking is associated with disease severity 3
• Weight management - weight loss interventions have been associated with HS regression 5
• Dietary modifications - elimination of dairy and brewer's yeast may benefit some patients 5

Special Considerations

• Screen for associated comorbidities including depression, anxiety, metabolic syndrome, inflammatory bowel disease, and arthritis 3
• In patients with history of malignancy requiring biologics, consider secukinumab or ustekinumab if malignancy occurred within the last 5 years 3
• For patients with latent TB requiring biologics, start prophylactic antibiotics at least 1 month before biologic initiation 3

Treatment Algorithm

1. Mild disease (Hurley I): Topical clindamycin and/or oral tetracyclines for 12 weeks 3
2. Moderate disease (Hurley II) or inadequate response: Clindamycin/rifampicin combination for 10-12 weeks 3
3. Inadequate response: Consider acitretin, dapsone, or anti-androgens 3
4. Moderate-to-severe disease (Hurley II-III) unresponsive to conventional therapy: Adalimumab 40mg weekly 3, 1
5. Inadequate response to adalimumab: Consider infliximab, secukinumab, or ustekinumab 3
6. Severe disease (Hurley III) or inadequate response to medical therapy: Surgical intervention 3

Common Pitfalls to Avoid

• Delaying treatment - early intervention is crucial to prevent irreversible skin damage 2
• Relying solely on incision and drainage - this provides only temporary relief 3
• Using etanercept - not recommended for HS 3
• Using adalimumab every other week - insufficient dosing; weekly dosing is required 3, 1
• Neglecting comorbidities - screen and manage associated conditions 3