What are the treatment options for outpatient management of hidradenitis suppurativa (HS)?

Outpatient Treatment Options for Hidradenitis Suppurativa

For outpatient management of hidradenitis suppurativa (HS), a stepwise approach based on disease severity is recommended, 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 to guide appropriate treatment selection 3
• Monitor treatment response using the Hidradenitis Suppurativa Clinical Response (HiSCR), which measures reduction in inflammatory lesions 3
• Assess patient-reported outcomes including pain (Visual Analog Scale) and quality of life (Dermatology Life Quality Index) 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, 3
• Adjunctive topical options:
  • Antiseptic washes (chlorhexidine, benzoyl peroxide, zinc pyrithione) 1, 2
  • Resorcinol 15% cream (keratolytic and antiseptic) for flares and daily between flares 1, 4
  • Intralesional triamcinolone (10 mg/mL) for acute, localized flares 1

Moderate Disease (Hurley Stage II)

• First-line therapy: Oral tetracyclines (doxycycline 100 mg once or twice daily or lymecycline 408 mg daily) for at least 12 weeks 1, 3
• Second-line therapy: Combination of clindamycin 300 mg twice daily and rifampin 300 mg twice daily for 10-12 weeks 1
• Alternative options:
  • Dapsone (starting at 50 mg daily, titrating up to 200 mg daily) 1, 5
  • Acitretin 0.3-0.5 mg/kg/day (for males and non-fertile females) 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, 3
• Second-line biologic therapy: Infliximab 5 mg/kg at weeks 0,2,6, and every 8 weeks thereafter 1
• Alternative options:
  • Moxifloxacin, metronidazole, and rifampin combination (as rescue therapy or bridge to other treatments) 1
  • Ertapenem 1g daily for 6 weeks (as rescue therapy or during surgical planning) 1, 2

Special Populations

Pediatric Patients

• Topical therapies: Similar approach to adult populations, with antiseptic washes to decrease bacterial resistance 1
• Systemic antibiotics:
  • Oral doxycycline for patients 8 years and older 1
  • Oral minocycline for patients 8 years and older with doxycycline intolerance 1
  • Combination therapy with oral rifampin and clindamycin 1
• Biologics:
  • Adalimumab for patients 12 years and older (FDA-approved) 1
  • Adalimumab for patients aged 2-11 (suggested) 1
  • Infliximab or secukinumab for patients 6 years and older 1

Female Patients

• Anti-androgen options:
  • Spironolactone for adolescent and adult females 1
  • Combined oral contraceptives 1
  • Metformin (especially with insulin resistance or PCOS) 1, 3

Adjunctive Therapies

• Screen for associated comorbidities including depression, anxiety, and cardiovascular risk factors 1, 3
• Encourage weight loss for patients with obesity 3, 6
• Recommend smoking cessation 1, 3
• Provide appropriate wound care for draining lesions 1, 7
• Consider pain management with NSAIDs for symptomatic relief 3, 7

Treatments Not Recommended

• Isotretinoin (unless there are concomitant moderate-to-severe acneiform lesions) 1
• Adalimumab 40 mg every other week (insufficient dosing) 1
• Etanercept 1
• Cryotherapy during acute flares (due to pain) 1
• Microwave ablation 1

Important Considerations

• Treatment recurrence rates are high after discontinuation, particularly with antibiotic regimens 1, 5
• Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1, 2
• Early intervention is crucial to prevent irreversible skin damage 6, 8
• For refractory cases, consider surgical interventions such as deroofing or extensive excision 1, 3
• A multimodal approach with treatment stacking (combining different therapeutic modalities) often yields better results 8