What are the treatment options for Hidradenitis suppurativa?

Treatment Options for 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, 3

Disease Assessment

• Evaluate disease severity using the Hurley staging system (I, II, III for mild, moderate, severe) to guide appropriate treatment selection 1, 3
• Monitor treatment response using the Hidradenitis Suppurativa Clinical Response (HiSCR), which measures reduction in inflammatory lesions 1, 3
• Assess patient-reported outcomes including pain (using Visual Analog Scale) and quality of life (using Dermatology Life Quality Index) 1, 3

Treatment Algorithm Based on Disease Severity

Mild Disease (Hurley Stage I)

• First-line: Topical clindamycin 1% solution/gel twice daily for 12 weeks 1, 2, 3
• Alternative first-line: Tetracycline 500 mg twice daily or doxycycline 100 mg once or twice daily for up to 4 months for more widespread mild disease 4, 2, 3

Moderate Disease (Hurley Stage II)

• First-line: Oral tetracycline (e.g., lymecycline 408 mg or doxycycline 100 mg) once or twice daily for 12 weeks 4, 1
• Second-line: Clindamycin 300 mg twice daily with rifampicin 300-600 mg daily (either once daily or 300 mg twice daily) for 10-12 weeks 4, 1, 2, 3
• Consider treatment break after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 4

Severe Disease (Hurley Stage III or Refractory Cases)

• First-line: Adalimumab (FDA-approved for moderate to severe HS) with an initial dose of 160 mg on day 1 (given in one day or split over two consecutive days), 80 mg at week 2, then 40 mg weekly starting at week 4 1, 2, 5
• Alternative options for patients unresponsive to adalimumab:
  • Acitretin 0.3-0.5 mg/kg/day (for male or non-fertile female patients) 4
  • Dapsone 4
  • Surgical intervention 4, 1, 3

Surgical Interventions

• Deroofing for recurrent nodules and tunnels 1, 2, 3
• Radical surgical excision for extensive disease with sinus tracts and scarring 4, 1, 2
• Healing by secondary intention, TDAP flap, or other reconstructive methods 4, 6

Special Populations

• For adolescents (12 years and older) with moderate to severe disease, adalimumab is FDA-approved 1, 5
  • For 30-60 kg: 80 mg on day 1, then 40 mg every other week starting at day 8 5
  • For ≥60 kg: 160 mg on day 1 (or split over two days), 80 mg on day 15, then 40 mg weekly or 80 mg every other week starting at day 29 5
• For children aged 8 years and older requiring systemic antibiotics, oral doxycycline is recommended 1

Adjunctive Therapies

• Weight loss for patients with obesity 1, 2, 3
• Smoking cessation, as tobacco use is associated with worse outcomes 1, 3
• Pain management with NSAIDs for symptomatic relief 1, 3
• Appropriate wound care for draining lesions 1, 3
• Screen for depression/anxiety 4
• Screen for treatable cardiovascular risk factors (measure BP, lipids, HbA1c) 4

Monitoring and Follow-up

• Assess treatment response after 12 weeks using HiSCR and patient-reported outcomes 4, 1, 3
• For adalimumab, if clinical response is not achieved after 16 weeks, consider alternative treatments 1, 5
• Be aware that non-surgical methods rarely result in lasting cure for advanced disease 1, 3

Treatment Limitations

• Currently, there is insufficient evidence to recommend numerous therapies including alitretinoin, anakinra, apremilast, atorvastatin, azathioprine, ciclosporin, colchicine, cyproterone, finasteride, fumaric acid esters, hydrocortisone, hyperbaric oxygen therapy, intravenous antibiotics, isoniazid, laser and photodynamic therapies, methotrexate, oral prednisolone, oral zinc, phototherapy, photochemotherapy, radiotherapy, secukinumab, spironolactone, staphage lysate, tolmetin sodium and ustekinumab 4
• Cryotherapy and microwave ablation are not recommended for treating lesions during the acute phase 4