What is the treatment for hidradenitis suppurativa?

Treatment of Hidradenitis Suppurativa

The treatment of hidradenitis suppurativa should follow a stepwise approach based on disease severity, with topical clindamycin for mild disease, oral antibiotics for moderate disease, and adalimumab for severe or refractory cases. 1, 2

Disease Assessment

• Evaluate disease severity using the Hurley staging system (stages I-III) to guide appropriate treatment selection 2
• Monitor treatment response using the Hidradenitis Suppurativa Clinical Response (HiSCR), which measures reduction in inflammatory lesions 1
• Assess patient-reported outcomes including pain (Visual Analog Scale) and quality of life (Dermatology Life Quality Index) 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
• Alternative first-line therapy: Tetracycline 500 mg twice daily for up to 4 months for more widespread mild disease 1
• For acute, localized flares: Intralesional triamcinolone (10 mg/mL) can provide significant reduction in erythema, edema, suppuration, and pain 1

Moderate Disease (Hurley Stage II)

• First-line therapy: Clindamycin 300 mg twice daily with rifampicin 600 mg once daily (or 300 mg twice daily) for 10-12 weeks 1, 3
• Tetracycline antibiotics (doxycycline, minocycline) have shown efficacy in moderate disease with fewer deep inflammatory lesions 4
• For patients not responding to antibiotics, consider advancing to biologic therapy 1, 2

Severe Disease (Hurley Stage III)

• First-line therapy: Adalimumab (Humira) is FDA-approved for moderate to severe hidradenitis suppurativa in patients 12 years and older 5
• Adalimumab dosing: Initial dose of 160 mg (day 1), followed by 80 mg (day 15), then 40 mg weekly starting at day 29 5
• For patients who fail adalimumab: Consider infliximab 5 mg/kg at weeks 0,2,6, and every 2 months thereafter for 12 weeks 1

Surgical Interventions

• Surgical treatment is often necessary for lasting cure, especially in advanced disease 1
• Options include:
  • Deroofing for recurrent nodules and tunnels 2
  • Radical surgical excision for severe disease with extensive sinus tracts and scarring 1
• The width of excision (rather than wound closure technique) influences therapeutic outcome 1

Special Populations

Pediatric Patients

• For children aged 12 years and older with moderate to severe disease: Adalimumab is FDA-approved 5
• For children aged 8 years and older requiring systemic antibiotics: Oral doxycycline is recommended 1
• For adolescent females requiring anti-androgens: Consider spironolactone or combined oral contraceptives 1

Adjunctive Therapies

• Weight loss should be encouraged for patients with obesity 2
• Smoking cessation is important as tobacco use is associated with worse outcomes 2, 6
• Pain management with NSAIDs for symptomatic relief 6
• Appropriate wound care for draining lesions 6

Monitoring and Follow-up

• Assess treatment response using HiSCR, which measures reduction in inflammatory lesions 1, 2
• Monitor for adverse effects, especially with biologics (serious infections, malignancy) 5
• Evaluate quality of life improvement using DLQI 2

Important Considerations and Pitfalls

• Antibiotics in HS are used for both antimicrobial and anti-inflammatory effects 7
• Early intervention is crucial to prevent irreversible skin damage and tunnel formation 8
• Recognize that HS is often associated with comorbidities (metabolic syndrome, inflammatory arthritis, inflammatory bowel disease) that may require additional management 8
• Be aware that non-surgical methods rarely result in lasting cure for advanced disease 1
• For adalimumab, if clinical response is not achieved after 16 weeks, consider alternative treatments 1