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

Disease Assessment

• Evaluate disease severity using the Hurley staging system to guide appropriate treatment selection 3
• Hurley Stage I: Recurrent nodules and abscesses with minimal or no scarring 3
• Hurley Stage II: One or limited number of sinuses and/or scarring within a body region 3
• Hurley Stage III: Multiple or extensive sinuses and/or scarring affecting an entire body region 3
• Monitor treatment response using the Hidradenitis Suppurativa Clinical Response (HiSCR), which measures reduction in inflammatory lesions 1, 2

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, 4
• Choice of skin cleanser is empiric, with chlorhexidine, benzoyl peroxide, and zinc pyrithione supported by expert opinion 4
• Intralesional triamcinolone (10 mg/mL) can be used for inflamed lesions, showing significant reduction in erythema, edema, suppuration, and pain 4

Moderate Disease (Hurley Stage II)

• First-line therapy: Tetracycline 500 mg twice daily for up to 4 months 4, 1
• Second-line therapy: Clindamycin 300 mg twice daily with rifampicin 300-600 mg daily for 10-12 weeks 4, 1
• Consider treatment break after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1

Severe Disease (Hurley Stage II/III)

• First-line biologic therapy: Adalimumab 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting at week 4 4, 1, 5
• Adalimumab demonstrated HiSCR response rates of 42-59% at week 12 compared to 26-28% for placebo 2
• If clinical response is not achieved after 16 weeks of adalimumab, consider alternative treatments 1, 2
• Second-line biologic: Infliximab 5 mg/kg at weeks 0,2,6, and every 2 months thereafter for 12 weeks 4, 1
• Alternative options for patients unresponsive to adalimumab include acitretin 0.3-0.5 mg/kg/day or dapsone 1

Surgical Interventions

• Surgical treatment is often necessary for lasting cure, especially in advanced disease 4, 1
• Radical surgical excision is recommended for extensive disease with sinus tracts and scarring 1, 4
• The width of the excision, not the wound closure technique, influences therapeutic outcome 4
• Options for wound closure include secondary intention healing, skin grafts, or flaps 4, 1

Special Populations

• For children aged 12 years and older with moderate to severe disease, adalimumab is FDA-approved 2, 5
• For adolescents weighing 30-60 kg: Day 1: 80 mg, Day 8 and subsequent doses: 40 mg every other week 5
• For adolescents weighing ≥60 kg: Day 1: 160 mg, Day 15: 80 mg, Day 29 and subsequent: 40 mg weekly or 80 mg every other week 5

Adjunctive Therapies

• Weight loss should be encouraged for patients with obesity 1, 6
• Smoking cessation is important as tobacco use is associated with worse outcomes 1, 6
• Pain management with NSAIDs for symptomatic relief 1
• Screen for depression/anxiety and treatable cardiovascular risk factors 1

Clinical Pearls and Pitfalls

• Non-responders at 12 weeks on adalimumab may still achieve response with continued treatment, with 40% of initial non-responders achieving response by week 36 2
• Response may be lost over time, with almost half of adalimumab responders at week 12 losing response by week 36 despite continued weekly dosing 2
• Non-surgical methods rarely result in lasting cure for advanced disease 4, 1
• Antibiotics represent a valid therapeutic approach despite advances in biologic therapies, and can be used in association with biologics for acute flares or as bridge therapy to surgery 7
• The British Journal of Dermatology states there is insufficient evidence to recommend numerous therapies, including alitretinoin, anakinra, apremilast, atorvastatin, azathioprine, ciclosporin, colchicine, cyproterone, finasteride, and others 1

Emerging Treatments

• Recent advances include approval of IL-17 inhibitors (secukinumab and bimekizumab) for moderate-to-severe disease 6
• There is a robust pipeline of immunomodulatory drugs in various stages of development 6
• Small molecule targets (JAK1 and PDE4 inhibitors) may provide effective new strategies for treatment 8