What are the treatment options for hidradenitis suppurativa?

Treatment of Hidradenitis Suppurativa

For hidradenitis suppurativa treatment, a stepwise approach based on disease severity is recommended, with topical clindamycin for mild disease, oral antibiotics for moderate disease, and adalimumab for severe or refractory cases. 1, 2, 3

Disease Assessment

• Evaluate disease severity using the Hurley staging system to guide appropriate treatment selection 2, 3
• Monitor treatment response using the Hidradenitis Suppurativa Clinical Response (HiSCR), which measures reduction in inflammatory lesions 1, 2
• Assess patient-reported outcomes including pain and quality of life 2, 3

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I)

• First-line: Topical clindamycin 1% solution/gel twice daily for 12 weeks 1, 2, 3
• Adjunctive options:
  • Intralesional triamcinolone (10 mg/mL) for inflamed lesions 1, 3
  • Resorcinol 15% cream to reduce pain and duration of abscesses (note: irritant dermatitis is a common side effect) 1
  • Consider skin cleansers such as chlorhexidine, benzoyl peroxide, or zinc pyrithione 1, 3

Moderate Disease (Hurley Stage II)

• First-line: Oral tetracycline (e.g., tetracycline 500 mg twice daily, lymecycline 408 mg, or doxycycline 100 mg once or twice daily) for up to 4 months 1, 2, 3
• Second-line: Clindamycin 300 mg twice daily with rifampicin 300-600 mg daily for 10-12 weeks 1, 2, 3
• Consider treatment break after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1

Severe Disease (Hurley Stage III)

• First-line: 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, 3, 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, 3
  • Infliximab 5 mg/kg at weeks 0,2,6, and every 2 months thereafter 1, 2
  • Ertapenem 1g daily for 6 weeks as rescue therapy or during surgical planning 1, 5

Surgical Interventions

• Deroofing for recurrent nodules and tunnels 1, 3
• Radical surgical excision for extensive disease with sinus tracts and scarring 1, 2, 3
• Options for wound closure include secondary intention healing, skin grafts, or flaps 1, 3

Special Populations

• For children aged 12 years and older with moderate to severe disease, adalimumab is FDA-approved 1, 3, 4
• For adolescents with HS weighing 30-60 kg: Day 1: 80 mg, Day 8 and subsequent doses: 40 mg every other week 4
• For adolescents weighing ≥60 kg: Day 1: 160 mg, Day 15: 80 mg, Day 29 and subsequent doses: 40 mg weekly or 80 mg every other week 4
• For children aged 8 years and older requiring systemic antibiotics, oral doxycycline is recommended 1

Adjunctive Therapies

• Weight loss should be encouraged for patients with obesity 1, 2, 3
• Smoking cessation is important as tobacco use is associated with worse outcomes 1, 2, 6
• Pain management with NSAIDs for symptomatic relief 2, 3
• Appropriate wound care for draining lesions 2, 3, 7
• Screen for depression/anxiety 1
• Screen for treatable cardiovascular risk factors (measure BP, lipids, HbA1c) 1

Treatment Monitoring

• Assess treatment response after 12 weeks using HiSCR and patient-reported outcomes 1, 2
• For adalimumab, if clinical response is not achieved after 16 weeks, consider alternative treatments 2, 4
• Monitor for adverse effects with biologics, particularly serious infections and malignancy 4

Treatment Limitations

• There is insufficient evidence to recommend numerous therapies, including alitretinoin, anakinra, apremilast, atorvastatin, azathioprine, ciclosporin, colchicine, cyproterone, finasteride, fumaric acid esters, hydrocortisone, hyperbaric oxygen therapy, intravenous antibiotics, isoniazid, laser and photodynamic therapies, methotrexate, oral prednisolone, oral zinc, phototherapy, photochemotherapy, radiotherapy, secukinumab, spironolactone, staphage lysate, tolmetin sodium, and ustekinumab 1
• Cryotherapy and microwave ablation are not recommended for treating lesions during the acute phase 1
• Be aware that non-surgical methods rarely result in lasting cure for advanced disease 1, 8

Important Considerations

• Topical clindamycin may increase rates of Staphylococcus aureus resistance; consider combining with benzoyl peroxide to reduce this risk 1
• When using adalimumab, perform test for latent TB; if positive, start treatment for TB prior to starting adalimumab 4
• Monitor all patients on biologics for active TB during treatment, even if initial latent TB test is negative 4