What are the treatment options for hidradenitis suppurativa?

Treatment Options for Hidradenitis Suppurativa

The treatment of hidradenitis suppurativa (HS) 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

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

Treatment Algorithm Based on Disease Severity

Mild Disease (Hurley Stage I)

• First-line: Topical clindamycin 1% solution/gel twice daily for 12 weeks 1, 2
• Intralesional triamcinolone (10 mg/mL) can be used for inflamed lesions 1
• Consider deroofing for recurrent nodules 2

Moderate Disease (Hurley Stage II)

• First-line: Tetracycline 500 mg twice daily for up to 4 months 3, 1
• Second-line: Clindamycin 300 mg twice daily with rifampicin 600 mg once daily (or 300 mg twice daily) for 10-12 weeks 3, 1, 2
• Consider surgical intervention for recurrent nodules and tunnels 2

Severe Disease (Hurley Stage III)

• First-line: Adalimumab 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting at week 4 3, 2, 4
• Second-line: Infliximab 5 mg/kg at weeks 0,2,6, and every 2 months thereafter for 12 weeks 3, 1
• Surgical intervention: Radical excision for extensive disease with sinus tracts and scarring 1, 5

Surgical Interventions

• Deroofing for recurrent nodules and tunnels 2
• Wide local excision for extensive chronic lesions 2
• Healing by secondary intention, skin grafts, or flaps for wound closure 1, 5

Special Populations

• For children aged 12 years and older with moderate to severe disease, adalimumab is FDA-approved 4
• For children aged 8 years and older requiring systemic antibiotics, oral tetracyclines can be used with careful attention to age restrictions and dosing 3
• Finasteride may be beneficial in early-onset HS, especially in patients with endocrine comorbidities 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, 5
• Pain management with NSAIDs for symptomatic relief 5
• Appropriate wound care for draining lesions 3, 5
• Screen for depression/anxiety, which is common in HS patients 1, 5
• Screen for cardiovascular risk factors (BP, lipids, HbA1c) 1, 5

Treatment Monitoring and Follow-up

• Assess treatment response after 12 weeks using HiSCR and patient-reported outcomes 1
• For adalimumab, if clinical response is not achieved after 16 weeks, consider alternative treatments 3, 2
• Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1

Important Considerations and Pitfalls

• Non-surgical methods rarely result in lasting cure for advanced disease; surgery is often necessary for lasting results in severe cases 1, 6
• Topical clindamycin may increase rates of Staphylococcus aureus resistance; consider combining with benzoyl peroxide to reduce this risk 1
• Be aware that HS is often misdiagnosed outside specialized clinics and inappropriately treated as a simple boil or abscess 6
• HS has significant comorbidities (obesity, metabolic syndrome, inflammatory arthritis, inflammatory bowel disease) that should be addressed 7
• Early intervention is crucial to prevent irreversible skin damage and tunnel formation 7