What are the treatment options for Hidradenitis Suppurativa (HS)?

Treatment Options for Hidradenitis Suppurativa (HS)

The treatment of hidradenitis suppurativa should follow a stepwise approach based on disease severity, with topical treatments for mild disease, oral antibiotics for moderate disease, and biologics like adalimumab for severe or refractory cases. 1, 2, 3

Disease Assessment

• Evaluate HS severity using the Hurley staging system (stages I-III) to guide appropriate treatment selection 4
• Monitor treatment response using the Hidradenitis Suppurativa Clinical Response (HiSCR), which measures reduction in inflammatory lesions 2, 4
• Assess patient-reported outcomes including pain and quality of life 1, 4

First-Line Treatments

• For mild disease (Hurley Stage I):
  • Topical clindamycin 1% solution/gel twice daily for 12 weeks 2, 3
  • Consider intralesional corticosteroid injections for carefully selected individual lesions during acute phase 1
• For more widespread mild to moderate disease:
  • Oral tetracyclines (doxycycline 100 mg once or twice daily or lymecycline 408 mg daily) for at least 12 weeks 1, 2
  • Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1, 2

Second-Line Treatments

• For moderate disease unresponsive to tetracyclines:
  • Combination therapy with oral clindamycin 300 mg twice daily and rifampicin 300 mg twice daily for 10-12 weeks 1, 2, 3
  • Be aware that recurrence rates are high after discontinuation of this combination therapy 5

Third-Line Treatments

• For moderate-to-severe disease unresponsive to conventional systemic therapy:
  • Adalimumab 40 mg weekly (FDA-approved for patients 12 years and older) 1, 2, 6
  • Initial dosing: 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting at week 4 3, 6
  • Note: Adalimumab 40 mg every other week is not recommended for HS 1
• For patients unresponsive to adalimumab:
  • Consider infliximab 5 mg/kg every 8 weeks 1, 2
  • Consider acitretin 0.3-0.5 mg/kg/day in males and non-fertile females 1, 2
  • Consider dapsone as an alternative option 1, 2

Surgical Interventions

• Consider extensive surgical excision in patients with HS when:
  • Conventional systemic treatments have failed 1
  • There is extensive disease with sinus tracts and scarring 2, 3
• Consider secondary intention healing or TDAP (thoracodorsal artery perforator) flap closure for axillary wounds following extensive excision 1
• Deroofing procedures may be beneficial for recurrent nodules and tunnels 2, 3

Adjunctive Therapies

• Screen patients for associated comorbidities including depression, anxiety, and cardiovascular risk factors 1, 2
• Refer patients to smoking-cessation services where relevant 1
• Refer patients to weight-management services where relevant 1, 2
• Provide pain management and appropriate wound dressings for draining lesions 1, 4

Treatments Not Recommended

• Do not offer isotretinoin unless there are concomitant moderate-to-severe acneiform lesions 1
• Do not offer etanercept 1
• Do not offer cryotherapy to treat lesions during the acute phase due to pain from the procedure 1, 2
• Do not offer microwave ablation 1

Monitoring

• In patients with long-standing, moderate-to-severe HS, monitor for:
  • Fistulating gastrointestinal disease
  • Inflammatory arthritis
  • Genital lymphoedema
  • Cutaneous squamous cell carcinoma
  • Anemia 1
• For patients on adalimumab, assess treatment response after 12-16 weeks using HiSCR and patient-reported outcomes 2, 3

Special Populations

• For children aged 12 years and older with moderate-to-severe disease, adalimumab is FDA-approved 4, 6
• For females with HS and polycystic ovary syndrome or during pregnancy, consider metformin 1

The treatment approach should be tailored based on disease severity, with early intervention to prevent irreversible skin damage. Be aware that non-surgical methods rarely result in lasting cure for advanced disease 2, 7.