What are the treatment options for hidradenitis suppurativa?

Treatment Options for Hidradenitis Suppurativa

Treatment of hidradenitis suppurativa should follow a stepwise approach based on disease severity, with topical therapies for mild disease, oral antibiotics for moderate disease, and biologics 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 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 and quality of life 3

Treatment Algorithm Based on Disease Severity

Mild Disease (Hurley Stage I)

• First-line therapy: Topical clindamycin 1% solution/gel twice daily for 12 weeks 1, 2
• 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 1, 2
• For acute lesions: Antiseptic washes, warm compresses, intralesional steroids, and incision and drainage for pain relief 4

Moderate Disease (Hurley Stage II)

• First-line therapy: Tetracyclines (e.g., doxycycline 100 mg once or twice daily) for 12 weeks 1
• Second-line therapy: Clindamycin 300 mg twice daily with rifampicin 300-600 mg daily for 10-12 weeks 1, 2
• Consider deroofing or excision for recurrent nodules and tunnels 4, 2

Severe Disease (Hurley Stage III)

• First-line therapy: Adalimumab 160 mg at week 0,80 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 1
  • Dapsone 1
  • Surgical intervention 1

Surgical Interventions

• Incision and drainage only for acute abscesses to relieve pain (not recommended as definitive treatment) 4
• Deroofing for recurrent nodules and tunnels 4, 2
• Wide local excision (scalpel, CO2, or electrosurgical) for extensive chronic lesions with sinus tracts and scarring 4, 1
• Wound healing may occur through secondary intention, primary closure, flaps, grafts, or skin substitutes 4

Laser and Light Therapies

• Neodymium-doped yttrium-aluminum-garnet (Nd:YAG) laser recommended for Hurley stage II or III disease 4
• Carbon dioxide (CO2) laser excision recommended for Hurley stage II or III disease with fibrotic sinus tracts 4

Hormonal Therapies

• Consider hormonal agents (estrogen-containing combined oral contraceptives, spironolactone, cyproterone acetate, metformin, finasteride) in appropriate female patients 4
• Avoid progestogen-only contraceptives as they may worsen HS 4

Adjunctive Therapies

• Weight loss for patients with obesity 2, 3
• Smoking cessation as tobacco use is associated with worse outcomes 1, 3
• Pain management with NSAIDs for symptomatic relief 3
• Appropriate wound care following principles of best-practice individualized wound care 4
• Screening for depression/anxiety and cardiovascular risk factors 1

Special Populations

• For children aged 12 years and older with moderate to severe disease, adalimumab is FDA-approved 3, 5
• For adolescents 12 years and older with hidradenitis suppurativa, adalimumab dosing is weight-based:
  • 30-60 kg: 80 mg on day 1, then 40 mg every other week starting on day 8 5
  • ≥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 on day 29 5

Treatment Limitations

• Non-surgical methods rarely result in lasting cure for advanced disease 1, 6
• For adalimumab, if clinical response is not achieved after 16 weeks, consider alternative treatments 1
• Be aware of potential serious infections and malignancy risks with TNF blockers like adalimumab 5
• Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1

Emerging Treatments

• Newer biologics targeting IL-17 (secukinumab and bimekizumab) have expanded drug therapy options for moderate-to-severe disease 6
• There is a robust pipeline of immunomodulatory drugs in various stages of development 6, 7

The management of hidradenitis suppurativa requires early intervention to prevent irreversible skin damage, adequate control of symptoms including pain, and addressing associated comorbidities 6.