What is the best treatment option for hidradenitis suppurativa?

Treatment Algorithm for Hidradenitis Suppurativa

The optimal 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, 3

Disease Assessment and Staging

• 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 2, 3
• Assess patient-reported outcomes including pain (Visual Analog Scale) and quality of life (Dermatology Life Quality Index) 2, 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, 3
• Adjunctive skin cleansers such as chlorhexidine, benzoyl peroxide, and zinc pyrithione can be used 2
• Intralesional triamcinolone (10 mg/mL) for inflamed lesions, showing significant reduction in erythema, edema, suppuration, and pain 2
• Consider combining topical clindamycin with benzoyl peroxide to reduce risk of Staphylococcus aureus resistance 2

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, 3
• Second-line therapy: 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 or Refractory Moderate Disease)

• First-line therapy: Adalimumab with an initial dose of 160 mg at week 0, followed by 80 mg at week 2, then 40 mg weekly starting at week 4 2, 3, 4
• Alternative options for patients unresponsive to adalimumab:
  • Acitretin 0.3-0.5 mg/kg/day 1, 2
  • Dapsone (starting at 50 mg daily and titrating up to 200 mg daily) 1, 2
  • Infliximab 5 mg/kg at weeks 0,2,6, and every 2 months thereafter 2, 3

Surgical Interventions

• Consider surgical intervention for patients unresponsive to medical therapy 1, 2, 3
• Radical surgical excision is recommended for extensive disease with sinus tracts and scarring 1, 2, 3
• Options for wound closure include secondary intention healing, skin grafts, or flaps 1, 2, 5
• Surgical treatment is often necessary for lasting cure, especially in advanced disease 5

Special Populations

• For children aged 12 years and older with moderate to severe disease, adalimumab is FDA-approved 4
• For pregnant patients requiring biologics, adalimumab is recommended 3

Adjunctive Therapies

• Encourage weight loss for patients with obesity 2, 3
• Recommend smoking cessation as tobacco use is associated with worse outcomes 2, 3
• Screen for depression/anxiety and treatable cardiovascular risk factors (measure BP, lipids, HbA1c) 1, 2, 3

Treatment Pitfalls and Caveats

• Adalimumab must be dosed appropriately - 40 mg every other week is insufficient and not recommended 2, 3
• Non-surgical methods rarely result in lasting cure for advanced disease 2, 5
• For adalimumab, if clinical response is not achieved after 16 weeks, consider alternative treatments 2, 3
• Do not offer isotretinoin unless there are concomitant moderate-to-severe acneiform lesions of the face or trunk 3
• Avoid cryotherapy and microwave ablation for treating lesions during the acute phase 1, 3

Monitoring and Follow-up

• Assess treatment response after 12 weeks using HiSCR and patient-reported outcomes 1, 2, 3
• For adalimumab, continue treatment only if there is evidence of clinical response 4
• Regular follow-up is essential to adjust treatment based on response and disease progression 2