What is the treatment for hydradenitis?

Treatment of Hidradenitis Suppurativa

The treatment of hidradenitis suppurativa 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 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 (Dermatology Life Quality Index) 3

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
• Adjunctive skin cleansers: chlorhexidine, benzoyl peroxide, and zinc pyrithione 4, 3
• Intralesional triamcinolone (10 mg/mL, 0.2-2.0 mL) for inflamed lesions, showing significant reduction in erythema, edema, suppuration, and pain 4
• Resorcinol 15% cream can reduce pain and duration of abscesses, though irritant dermatitis is a common side effect 4

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, 5
• Second-line therapy: Clindamycin 300 mg twice daily with rifampicin 300-600 mg daily for 10-12 weeks 4
• Treatment typically lasts 8 to 12 weeks and can be repeated intermittently 4

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
• 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
  • Ertapenem 1g daily for 6 weeks as rescue therapy or during surgical planning 1

Surgical Interventions

• 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
• Surgical intervention should be considered for patients unresponsive to medical therapy 3

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
• Screen for depression/anxiety and treatable cardiovascular risk factors (measuring BP, lipids, HbA1c) 1, 3

Treatment Pitfalls and Caveats

• Topical clindamycin may increase rates of Staphylococcus aureus resistance; consider combining with benzoyl peroxide to reduce this risk 4
• Adalimumab must be dosed appropriately - 40 mg every other week is insufficient 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
• Antibiotic resistance is a concern with long-term antibiotic use; consider treatment breaks to assess need for ongoing therapy 1, 6
• The bacterial flora in HS is often polymicrobial with up to 5 species, predominantly staphylococci and bacteria of intestinal flora 7
• Penicillins with β-lactamase inhibitors or fluoroquinolones could serve as alternative antibiotics when first-line treatments fail 7

Monitoring and Follow-up

• Assess treatment response after 12 weeks using HiSCR and patient-reported outcomes 1, 3
• Regular follow-up is essential to adjust treatment based on response and disease progression 3
• Consider combination approaches with antibiotics and biologics for management of acute flares or as bridge therapy to surgery 6