What is the acute treatment for hidradenitis suppurativa?

Acute Treatment for Hidradenitis Suppurativa

For acute treatment of hidradenitis suppurativa, first-line therapy should be topical clindamycin 1% solution/gel twice daily for mild disease, oral antibiotics (tetracycline or clindamycin plus rifampicin) for moderate disease, and adalimumab for severe disease. 1, 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 1, 2
• Intralesional triamcinolone (10 mg/mL) can be used for inflamed lesions, showing significant reduction in erythema, edema, suppuration, and pain 1
• Alternative first-line treatment for more widespread mild disease: Tetracycline 500 mg twice daily or doxycycline 100 mg once or twice daily for up to 4 months 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 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)

• First-line therapy: Adalimumab with an initial dose of 160 mg, followed by 80 mg at week 2, then 40 mg weekly starting at week 4 1, 2, 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, 4
  • Infliximab 5 mg/kg at weeks 0,2,6, and every 2 months thereafter for 12 weeks 1, 2

Surgical Interventions for Acute Management

• Radical surgical excision is recommended for extensive disease with sinus tracts and scarring 1, 2
• Deroofing procedures for recurrent nodules and tunnels 2
• Options for wound closure include secondary intention healing, skin grafts, or flaps 1, 4

Monitoring Treatment Response

• Assess treatment response after 12 weeks using Hidradenitis Suppurativa Clinical Response (HiSCR), which measures reduction in inflammatory lesions 1, 2
• Evaluate quality of life improvement using Dermatology Life Quality Index (DLQI) 2, 4
• For adalimumab, if clinical response is not achieved after 16 weeks, consider alternative treatments 2, 4

Special Populations

• For children aged 12 years and older with moderate to severe disease, adalimumab is FDA-approved 2, 3
• For children aged 8 years and older requiring systemic antibiotics, oral doxycycline is recommended 1

Adjunctive Therapies

• Pain management with NSAIDs for symptomatic relief 2
• Weight loss should be encouraged for patients with obesity 2
• Smoking cessation is important as tobacco use is associated with worse outcomes 2
• Appropriate wound care for draining lesions 2

Important Considerations and Pitfalls

• Non-surgical methods rarely result in lasting cure for advanced disease 2
• 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
• Antibiotics should be used not only for their antimicrobial effects but also for their anti-inflammatory properties 5
• The British Journal of Dermatology recommends against cryotherapy and microwave ablation for treating lesions during the acute phase 1
• Consider ertapenem 1g daily for 6 weeks as rescue therapy or during surgical planning for severe disease requiring IV antibiotics 4