When to treat hidradenitis suppurativa?

When to Treat Hidradenitis Suppurativa

Treatment for hidradenitis suppurativa should be initiated immediately upon diagnosis, with therapy selection based on disease severity according to the Hurley staging system. 1, 2

Disease Severity Assessment and Treatment Algorithm

• Evaluate disease severity using the Hurley staging system to guide appropriate treatment selection 1, 2
• Monitor treatment response using the Hidradenitis Suppurativa Clinical Response (HiSCR), which measures reduction in inflammatory lesions 1
• Assess patient-reported outcomes including pain (Visual Analog Scale) and quality of life (DLQI) 3, 1

Treatment Based on Disease Severity

Mild Disease (Hurley Stage I)

• First-line therapy: Topical clindamycin 1% solution/gel twice daily for 12 weeks 3, 1, 2
• For localized inflammatory lesions: Intralesional triamcinolone (10 mg/mL) can be used 1
• For more widespread mild disease: Tetracycline 500 mg twice daily or doxycycline 100 mg once or twice daily for up to 4 months 3, 1, 2

Moderate Disease (Hurley Stage II)

• First-line therapy: Tetracycline 500 mg twice daily for up to 4 months 1, 2
• Second-line therapy: Clindamycin 300 mg twice daily with rifampicin 600 mg once daily (or 300 mg twice daily) for 10-12 weeks 3, 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 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting at week 4 3, 1, 2
• If adalimumab fails after 16 weeks, consider: 1
  • Infliximab 5 mg/kg at weeks 0,2,6, and every 2 months thereafter 1
  • Acitretin 0.3-0.5 mg/kg/day 1
  • Dapsone (starting at 50 mg daily and titrating up to 200 mg daily) 1

Surgical Interventions

• Consider surgical options for all patients depending on type and extent of scarring 3
• For recurrent nodules and tunnels: Deroofing procedures 1, 2
• For extensive disease with sinus tracts and scarring: Radical surgical excision 3, 1, 2
• Options for wound closure include secondary intention healing, skin grafts, or flaps 1

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, 2
• Pain management with NSAIDs for symptomatic relief 1, 4
• Appropriate wound care for draining lesions 1, 4
• Screen for depression/anxiety 1, 4
• Screen for cardiovascular risk factors (measure BP, lipids, HbA1c) 1, 4

Treatment Limitations and Pitfalls

• Non-surgical methods rarely result in lasting cure for advanced disease 1
• For adalimumab, if clinical response is not achieved after 16 weeks, consider alternative treatments 1
• Recurrence rate is high after discontinuation of clindamycin plus rifampicin combination therapy 5
• When using retinoids like acitretin, teratogenicity must be considered in females of reproductive age 5
• Avoid cryotherapy and microwave ablation for treating lesions during the acute phase 1

Special Considerations

• For children aged 12 years and older with moderate to severe disease, adalimumab is FDA-approved 1
• For children aged 8 years and older requiring systemic antibiotics, oral doxycycline is recommended 1
• For extensive perianal disease, immediate referral to dermatology secondary care and surgical consultation is indicated 4