What are the new treatment guidelines for hidradenitis suppurativa?

New Treatment Guidelines for Hidradenitis Suppurativa

The most current treatment guidelines for hidradenitis suppurativa recommend a stepwise approach based on disease severity, with topical clindamycin for mild disease, oral antibiotics for moderate disease, and biologics (particularly adalimumab) for severe or refractory cases. 1, 2

Disease Assessment and Staging

• Evaluate disease severity using the Hurley staging system to guide appropriate treatment selection 2, 3
• Monitor treatment response using the Hidradenitis Suppurativa Clinical Response (HiSCR), which measures reduction in inflammatory lesions 2, 4
• Assess patient-reported outcomes including pain (Visual Analog Scale) and quality of life (Dermatology Life Quality Index) 1, 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 therapy: Tetracycline 500 mg twice daily or doxycycline 100 mg once or twice daily for up to 4 months 1
• Consider intralesional corticosteroid injections for carefully selected individual lesions during acute flares 1, 2

Moderate Disease (Hurley Stage II)

• First-line therapy: Oral tetracyclines such as doxycycline or lymecycline for at least 12 weeks 1, 2
• Second-line therapy: Clindamycin 300 mg twice daily with rifampicin 300-600 mg daily (either as 600 mg once daily or 300 mg twice daily) for 10-12 weeks 1, 5
• Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1, 2

Severe Disease (Hurley Stage III or Refractory Moderate Disease)

• First-line biologic therapy: Adalimumab 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting at week 4 1, 4
• If clinical response is not achieved after 16 weeks of adalimumab, consider alternative treatments 1, 2
• Second-line biologic therapy: Infliximab 5 mg/kg at weeks 0,2,6, and every 2 months thereafter for 12 weeks 1, 2
• Alternative options for patients unresponsive to biologics:
  • Acitretin 0.3-0.5 mg/kg/day (in males and non-fertile females) 1, 2
  • Dapsone 1, 2
  • Surgical intervention 1, 2

Surgical Interventions

• Consider extensive excision in patients with severe disease with sinus tracts and scarring 1
• Consider extensive excision when conventional systemic treatments have failed 1, 2
• Options for wound closure include secondary intention healing, skin grafts, or flaps 1, 2
• The width of the excision, rather than the wound closure technique, influences therapeutic outcome 1, 2

Special Populations

Pregnancy

• Metformin is recommended for pregnant patients requiring anti-androgens 1, 2
• Adalimumab is recommended for pregnant patients requiring biologics 1, 2
• Avoid oral doxycycline and erythromycin during pregnancy 1

Breastfeeding

• Metformin is suggested for breastfeeding patients requiring anti-androgens 1
• Limit use of oral doxycycline; if no suitable alternative is available, use should be limited to 3 weeks without repeating courses 1

Children and Adolescents

• Adalimumab is FDA-approved for children aged 12 years and older with moderate to severe disease 2, 3

Adjunctive Therapies

• Encourage weight loss for patients with obesity 2, 3, 6
• Recommend smoking cessation 1, 2, 5
• Screen for depression, anxiety, and cardiovascular risk factors 1, 2
• Consider metformin in patients with concomitant diabetes mellitus, and females with polycystic ovary syndrome 1, 2

Treatments Not Recommended

• Do not offer isotretinoin unless there are concomitant moderate-to-severe acneiform lesions of the face or trunk 1
• Do not offer adalimumab 40 mg every other week (insufficient dosing) 1, 4
• Do not offer etanercept 1
• Do not offer cryotherapy to treat lesions during the acute phase due to pain from the procedure 1
• Do not offer microwave ablation 1

Clinical Pearls and Pitfalls

• Non-responders at 12 weeks on adalimumab may still achieve response with continued treatment 4
• Response to adalimumab may be lost over time, with almost half of responders at week 12 losing response by week 36 despite continued weekly dosing 4
• High BMI and smoking habits appear to be predictive factors of poor response to antibiotics 5
• Non-surgical methods rarely result in lasting cure for advanced disease 1, 7