What is the treatment for facial hidradenitis suppurativa?

Treatment of Facial Hidradenitis Suppurativa

For facial hidradenitis suppurativa, treatment 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 Staging

• Evaluate disease severity using the Hurley staging system to guide appropriate treatment selection 2
• Monitor treatment response using the Hidradenitis Suppurativa Clinical Response (HiSCR), which measures reduction in inflammatory lesions 2
• Assess patient-reported outcomes including pain (Visual Analog Scale) and quality of life (Dermatology Life Quality Index) 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
• Skin cleansers such as chlorhexidine, benzoyl peroxide, and zinc pyrithione can be used as adjunctive therapy 1
• Intralesional triamcinolone (10 mg/mL) can be used for inflamed lesions, showing significant reduction in erythema, edema, suppuration, and pain 1
• Resorcinol 15% cream can reduce pain and duration of abscesses, though irritant dermatitis is a common side effect 3

Moderate Disease (Hurley Stage II)

• First-line therapy: Oral tetracycline (500 mg twice daily) or doxycycline (100 mg once or twice daily) for up to 4 months 1, 2
• 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 or Refractory Moderate Disease)

• 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, 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 1

Surgical Interventions

• Consider surgical intervention for patients unresponsive to medical therapy 1
• Radical surgical excision is recommended for extensive disease with sinus tracts and scarring 1, 2
• Options for wound closure include secondary intention healing, skin grafts, or flaps 1

Special Considerations for Facial HS

• Facial involvement requires particularly careful management due to cosmetic concerns and risk of scarring 5
• Early intervention is crucial to prevent irreversible skin damage and scarring in visible areas 5
• Consider lower threshold for biologic therapy in facial disease due to cosmetic impact and quality of life concerns 5

Adjunctive Therapies

• Weight loss should be encouraged for patients with obesity 2
• Smoking cessation is important as tobacco use is associated with worse outcomes 2
• Screen for depression/anxiety, which are common comorbidities 1
• Screen for treatable cardiovascular risk factors (measure BP, lipids, HbA1c) 1

Treatment Pitfalls and Caveats

• Topical clindamycin may increase rates of Staphylococcus aureus resistance; consider combining with benzoyl peroxide to reduce this risk 3
• Adalimumab must be dosed appropriately - 40 mg every other week is insufficient dosing and not recommended 2
• 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
• Isotretinoin is not recommended unless there are concomitant moderate-to-severe acneiform lesions 2
• Avoid cryotherapy and microwave ablation for treating lesions during the acute phase 1, 2

Monitoring and Follow-up

• Assess treatment response after 12 weeks using HiSCR and patient-reported outcomes 1
• For patients on biologics, monitor for adverse effects, especially serious infections 4
• Regular follow-up is essential to adjust treatment based on response and disease progression 2