What is the treatment for Hidradenitis suppurativa?

Treatment 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 and Staging

• Evaluate disease severity using the Hurley staging system to guide appropriate treatment selection 2
• Monitor treatment response using the Hidradenitis Suppurativa Clinical Response (HiSCR), which measures reduction in inflammatory lesions 1, 2
• 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)

• First-line therapy: Topical clindamycin 1% solution/gel twice daily for 12 weeks 3, 2
• Intralesional triamcinolone (10 mg/mL) can be used for inflamed lesions, showing significant reduction in erythema, edema, suppuration, and pain 3, 4
• Consider deroofing for recurrent nodules and tunnels 1

Moderate Disease (Hurley Stage II)

• First-line therapy: Oral tetracycline 500 mg twice daily for up to 4 months 1, 2
• Second-line therapy: Clindamycin 300 mg twice daily with rifampicin 300-600 mg daily for 10-12 weeks 3, 1, 2
• Consider treatment break after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1

Severe Disease (Hurley Stage III or Refractory Moderate Disease)

• First-line therapy: Adalimumab 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting at week 4 1, 4, 5
• Adalimumab demonstrated HiSCR response rates of 42% in PIONEER 1 and 59% in PIONEER 2 trials at week 12, compared to 26% and 28% for placebo 4
• Alternative options for patients unresponsive to adalimumab:
  • Acitretin 0.3-0.5 mg/kg/day 1
  • Dapsone (starting at 50 mg daily and titrating up to 200 mg daily) 3, 1
  • 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, 2
• Options include:
  • Deroofing for recurrent nodules and tunnels 1
  • Radical surgical excision for severe disease with extensive sinus tracts and scarring 1, 2
  • Healing by secondary intention, skin grafts, or flaps for wound closure 1, 2

Special Populations

• For children aged 12 years and older with moderate to severe disease, adalimumab is FDA-approved 5
• For pregnant patients requiring systemic therapy, metformin is recommended 2
• For pregnant patients requiring biologics, adalimumab is recommended 2

Adjunctive Therapies

• Weight loss should be encouraged for patients with obesity 2, 6
• Smoking cessation is important as tobacco use is associated with worse outcomes 1, 2
• Pain management with NSAIDs for symptomatic relief 1
• Screen for depression, anxiety, and cardiovascular risk factors 1, 2

Monitoring and Follow-up

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

Clinical Pearls and Pitfalls

• 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
• Avoid isotretinoin unless there are concomitant moderate-to-severe acneiform lesions of the face or trunk 2
• Do not offer adalimumab 40 mg every other week as this is insufficient dosing 2, 5
• Avoid cryotherapy to treat lesions during the acute phase due to pain from the procedure 1, 2
• For severe disease requiring IV antibiotics, ertapenem 1g daily for 6 weeks can be considered as rescue therapy or during surgical planning 3