Treatment of Hidradenitis Suppurativa
The treatment of hidradenitis suppurativa (HS) should follow a stepwise approach based on disease severity, with topical therapies for mild disease, oral antibiotics for moderate disease, and biologics or surgery for severe or refractory cases. 1
Disease Assessment and Staging
- Evaluate disease severity using the Hurley staging system (I-III) to guide appropriate treatment selection 2, 3
- Monitor treatment response using the Hidradenitis Suppurativa Clinical Response (HiSCR), which measures reduction in inflammatory lesions 2, 3
- Assess patient-reported outcomes including pain (Visual Analog Scale) and quality of life (Dermatology Life Quality Index) 1, 2
- Screen for associated comorbidities including depression, anxiety, cardiovascular risk factors, and inflammatory bowel disease 1, 3
Treatment Algorithm Based on Disease Severity
Mild Disease (Hurley Stage I)
- First-line: Topical clindamycin 1% solution/gel twice daily for 12 weeks 2, 3
- Antiseptic washes (chlorhexidine, benzoyl peroxide, zinc pyrithione) as adjunctive therapy 1, 2
- Intralesional triamcinolone (10 mg/mL) for inflamed individual lesions 1, 2
- Topical resorcinol 15% cream can reduce pain and duration of abscesses 1
Moderate Disease (Hurley Stage II)
- First-line: Oral tetracyclines (doxycycline 100 mg or lymecycline 408 mg) once or twice daily for at least 12 weeks 1
- Second-line: Combination of clindamycin 300 mg twice daily and rifampicin 300 mg twice daily for 10-12 weeks 1
- Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1, 2
Severe Disease (Hurley Stage III or Refractory Moderate Disease)
- First-line: Adalimumab 40 mg weekly (initial dose 160 mg, followed by 80 mg at week 2, then 40 mg weekly starting at week 4) 1, 3
- Second-line: Infliximab 5 mg/kg at weeks 0,2,6, and every 8 weeks thereafter 1, 3
- Alternative options for patients unresponsive to biologics:
Surgical Interventions
- Consider extensive excision for patients with severe disease with sinus tracts and scarring 1, 3
- Consider extensive excision when conventional systemic treatments have failed 1
- Healing options after excision include secondary intention healing or thoracodorsal artery perforator (TDAP) flap closure for axillary wounds 1
- Deroofing procedures may be considered for recurrent nodules and tunnels 3, 5
Adjunctive Therapies
- Encourage weight loss for patients with obesity 2, 3
- Recommend smoking cessation 1, 3
- Provide appropriate wound care and dressings for draining lesions 1, 5
- Treat pain with NSAIDs or other analgesics as needed 1, 2
- Consider metformin in patients with concomitant diabetes mellitus or in females with polycystic ovary syndrome 1, 2
Treatments Not Recommended
- Do not offer isotretinoin unless there are concomitant moderate-to-severe acneiform lesions of the face or trunk 1, 6
- Do not offer adalimumab 40 mg every other week (insufficient dosing) 1, 3
- Do not offer etanercept 1, 7
- Do not offer cryotherapy to treat lesions during the acute phase due to pain from the procedure 1, 3
- Do not offer microwave ablation 1, 3
Special Considerations
- For children aged 12 years and older with moderate to severe disease, adalimumab is FDA-approved 2, 5
- For pregnant patients requiring systemic therapy, metformin may be considered 1, 3
- Monitor for adverse effects with biologics, particularly serious infections 5, 8
Treatment Pitfalls and Caveats
- Recurrence is common after discontinuation of antibiotic therapy, particularly the clindamycin-rifampicin combination 4, 8
- Teratogenicity must be considered when prescribing acitretin to females of reproductive age 4, 6
- Non-surgical methods rarely result in lasting cure for advanced disease 1, 7
- For adalimumab, if clinical response is not achieved after 16 weeks, consider alternative treatments 2, 8