What are the treatment options for hidradenitis suppurativa (HS)?

Treatment of Hidradenitis Suppurativa

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, 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 and quality of life 2, 3

Treatment Options 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
  • Skin cleansers such as chlorhexidine, benzoyl peroxide, or zinc pyrithione 1, 3
  • Resorcinol 15% cream to reduce pain and duration of abscesses (watch for irritant dermatitis) 1

Moderate Disease (Hurley Stage II)

• First-line: Oral tetracycline (e.g., tetracycline 500 mg twice daily 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 1

Surgical Interventions

• Deroofing for recurrent nodules and tunnels 2, 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 2, 4
• For adolescents with HS, dosing of adalimumab is weight-based:
  • 30-60 kg: 80 mg on day 1, then 40 mg every other week starting day 8 4
  • ≥60 kg: 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 day 29 4

Adjunctive Therapies

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

Treatment Monitoring

• Assess treatment response after 12 weeks using HiSCR and patient-reported outcomes 1, 2, 3
• For adalimumab, if clinical response is not achieved after 16 weeks, consider alternative treatments 2, 3
• Be aware of potential serious adverse effects with biologics, including serious infections and malignancy 4

Important Considerations

• Topical clindamycin may increase rates of Staphylococcus aureus resistance; consider combining with benzoyl peroxide to reduce this risk 1
• Early intervention is crucial to prevent irreversible skin damage 5
• A combination of medical and surgical approaches is often necessary for optimal management 6, 7