What are the treatment options for hidradenitis suppurativa?

Treatment of Hidradenitis Suppurativa

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 2
• Monitor treatment response using the Hidradenitis Suppurativa Clinical Response (HiSCR), which measures reduction in inflammatory lesions 1, 3
• Assess patient-reported outcomes including pain (Visual Analog Scale) and quality of life (Dermatology Life Quality Index) 3, 2

Treatment Algorithm Based on Disease Severity

Mild Disease (Hurley Stage I/mild Stage II)

• First-line therapy: Topical clindamycin 1% solution/gel twice daily for 12 weeks 4, 1, 2
• Choice of skin cleanser is empiric, with options including chlorhexidine, benzoyl peroxide, and zinc pyrithione 4
• Intralesional triamcinolone (10 mg/mL) can be used for inflamed lesions, showing significant reduction in erythema, edema, suppuration, and pain 4, 1
• Alternative first-line therapy: 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

Moderate Disease (Hurley Stage II)

• First-line therapy: Oral tetracycline (e.g., lymecycline 408 mg or 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 (or 300 mg twice daily) for 10-12 weeks 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 Stage II)

• First-line therapy: Adalimumab 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting at week 4 1, 3, 5
  • Adalimumab demonstrated HiSCR response rates of 42% in PIONEER 1 and 59% in PIONEER 2 trials at week 12 3
  • Non-responders at 12 weeks may still achieve response with continued treatment 3
• 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) 1
  • Infliximab 5 mg/kg at weeks 0,2,6, and every 2 months thereafter for 12 weeks 1
  • Ertapenem 1g daily for 6 weeks as rescue therapy or during surgical planning 1

Surgical Interventions

• Deroofing for recurrent nodules and tunnels 1, 2
• Radical surgical excision for extensive disease with sinus tracts and scarring 1, 2
• Options for wound closure include secondary intention healing, skin grafts, or flaps 1

Special Populations

• Adalimumab is FDA-approved for children aged 12 years and older with moderate to severe hidradenitis suppurativa 1, 2, 5
• For adolescents 12 years and older with hidradenitis suppurativa, dosing is weight-based:
  • 30-60 kg: 80 mg on day 1, then 40 mg every other week starting 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 day 29 5

Adjunctive Therapies

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

Treatment Limitations and Pitfalls

• 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, 3
• 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 3
• The British Journal of Dermatology states there is insufficient evidence to recommend numerous therapies, including alitretinoin, anakinra, apremilast, atorvastatin, azathioprine, ciclosporin, colchicine, cyproterone, finasteride, fumaric acid esters, and many others 1
• Avoid cryotherapy and microwave ablation for treating lesions during the acute phase 1

Safety Considerations with Biologics

• Monitor for serious infections and malignancy with adalimumab therapy 5
• Perform test for latent TB before starting adalimumab; if positive, start treatment for TB prior to starting adalimumab 5
• Monitor all patients for active TB during treatment, even if initial latent TB test is negative 5