What is the treatment for Hidradenitis Suppurativa (HS) skin infection?

Treatment for Hidradenitis Suppurativa (HS)

The treatment for 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 Severity Assessment

• Evaluate HS severity using the Hurley staging system, which classifies patients into three stages based on the presence of abscesses, sinus tracts, and scarring 3
• Monitor treatment response using the Hidradenitis Suppurativa Clinical Response (HiSCR), which measures reduction in inflammatory lesions 1, 3
• Assess patient-reported outcomes including pain and quality of life 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 4, 1, 2
• Alternative first-line therapy for more widespread mild disease: Tetracycline 500 mg twice daily or doxycycline 100 mg once or twice daily for up to 4 months 4, 1
• Adjunctive options:
  • Intralesional triamcinolone (10 mg/mL) for inflamed lesions 1
  • Resorcinol 15% cream to reduce pain and duration of abscesses 1

Moderate Disease (Hurley Stage II)

• First-line therapy: Tetracycline 500 mg twice daily for up to 4 months 4, 1
• Second-line therapy: Clindamycin 300 mg twice daily with rifampicin 600 mg once daily (or 300 mg twice daily) for 10-12 weeks 4, 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 Cases)

• First-line therapy: Adalimumab 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting at week 4 4, 2, 5
• 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

• Deroofing for recurrent nodules and tunnels 1, 2
• Radical surgical excision for extensive disease with sinus tracts and scarring 4, 1, 2
• Options for wound closure include secondary intention healing, skin grafts, or flaps 1

Special Populations

• For adolescents (12 years and older) with moderate to severe disease:
  • Weight 30-60 kg: Adalimumab 80 mg on day 1, then 40 mg every other week starting on day 8 5
  • Weight ≥60 kg: Adalimumab 160 mg on day 1 (or split over two days), 80 mg on day 15, then 40 mg weekly or 80 mg every other week starting on day 29 5

Adjunctive Therapies

• Weight loss for patients with obesity 2, 3
• Smoking cessation 1
• Pain management with NSAIDs 1
• Appropriate wound care for draining lesions 6
• Screening for depression/anxiety 1
• Screening for cardiovascular risk factors 1

Treatment Limitations and Pitfalls

• Topical clindamycin may increase rates of Staphylococcus aureus resistance; consider combining with benzoyl peroxide to reduce this risk 1
• 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
• Be aware of potential serious infections and malignancy risk with biologic therapies 5
• There is insufficient evidence to recommend numerous therapies, including alitretinoin, anakinra, apremilast, atorvastatin, azathioprine, ciclosporin, colchicine, and others 1

Monitoring and Follow-up

• Assess treatment response after 12 weeks using HiSCR and patient-reported outcomes 1, 3
• For patients on biologics, monitor for adverse effects, especially serious infections 5
• Evaluate quality of life improvement using Dermatology Life Quality Index (DLQI) 3

The management of HS requires a comprehensive approach that addresses both the inflammatory and fibrotic components of the disease 7. While antibiotics remain a cornerstone of therapy due to their anti-inflammatory and antimicrobial properties 8, biologic therapies have become increasingly important for moderate-to-severe disease 9. Surgical intervention is often necessary for lasting cure, especially in advanced disease with extensive sinus tracts and scarring 7.