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 and Treatment Algorithm

• 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 1, 3
• Assess patient-reported outcomes including pain and quality of life 3

Treatment Options 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 1, 2, 3
• 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, 3
• Intralesional triamcinolone (10 mg/mL) can be used for inflamed lesions, showing significant reduction in erythema, edema, suppuration, and pain 1

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 for 10-12 weeks 1, 2, 3
• Consider treatment break after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1

Severe Disease (Hurley Stage III)

• First-line biologic therapy: Adalimumab 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting at week 4 1, 2, 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) 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 or excision for recurrent nodules and tunnels 2, 3
• Radical surgical excision for extensive disease with sinus tracts and scarring 1, 2, 3
• Options for wound closure include secondary intention healing, skin grafts, or flaps 1, 3

Special Populations

• For children aged 12 years and older with moderate to severe disease, adalimumab is FDA-approved 4
• For adolescents 12 years and older with hidradenitis suppurativa, adalimumab dosing is weight-based:
  • 30 kg to less than 60 kg: 80 mg on day 1, then 40 mg every other week starting on day 8 4
  • 60 kg and greater: 160 mg on day 1 (given in one day or split over two consecutive days), 80 mg on day 15, then 40 mg weekly or 80 mg every other week starting on day 29 4

Adjunctive Therapies

• Weight loss should be encouraged for patients with obesity 2, 3
• Smoking cessation is important as tobacco use is associated with worse outcomes 2
• Pain management with NSAIDs for symptomatic relief 3
• Appropriate wound care for draining lesions 5, 6
• Screen for depression/anxiety 1
• Screen for treatable cardiovascular risk factors (measure BP, lipids, HbA1c) 1

Treatment Limitations and Monitoring

• Assess treatment response after 12 weeks using HiSCR and patient-reported outcomes 1, 3
• For adalimumab, if clinical response is not achieved after 16 weeks, consider alternative treatments 1, 2
• Be aware that non-surgical methods rarely result in lasting cure for advanced disease 1, 2
• Discontinue adalimumab in adult patients without evidence of clinical remission by eight weeks (Day 57) of therapy 4

Important Considerations

• Hidradenitis suppurativa has a profound negative effect on patients' quality of life 7
• Comorbidities (e.g., metabolic syndrome, inflammatory arthritis, and inflammatory bowel disease) frequently accompany skin alterations due to systemic inflammation 7
• Early intervention is crucial to prevent irreversible skin damage 7, 8
• A multidisciplinary approach is necessary as HS lesions include both inflammation (amenable to medical treatment) as well as fibrosis (amenable to surgery only) 5, 9