What is the treatment for Hidradenitis Suppurativa?

Treatment of Hidradenitis Suppurativa

Treatment should follow a severity-based stepwise approach using the Hurley staging system, starting with topical clindamycin for mild disease, advancing to oral antibiotics for moderate disease, and utilizing adalimumab (the only FDA-approved biologic) for severe or refractory cases, with surgical intervention reserved for extensive disease with sinus tracts and scarring. 1, 2

Initial Assessment and Staging

• Record Hurley stage (I, II, or III) for the worst affected regions to guide treatment selection 1
• Measure pain using Visual Analog Scale (VAS) and quality of life using Dermatology Life Quality Index (DLQI) 1, 3
• Document lesion count and number of flares in the last month 1
• Screen for depression/anxiety and cardiovascular risk factors (blood pressure, lipids, HbA1c) 1
• For Hurley stage III (severe) disease, consider immediate referral to dermatology 1

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I)

• First-line: Topical clindamycin 1% solution/gel applied twice daily to affected skin regions for 12 weeks 1, 2
• Consider combining with benzoyl peroxide to reduce Staphylococcus aureus resistance risk 2
• Intralesional triamcinolone (10 mg/mL) can be used for individual inflamed lesions, providing significant reduction in erythema, edema, suppuration, and pain 2
• Alternative first-line: Oral tetracycline 500 mg twice daily or doxycycline 100 mg once or twice daily for up to 4 months for more widespread mild disease 2

Moderate Disease (Hurley Stage II)

• First-line: Oral tetracycline (lymecycline 408 mg or doxycycline 100 mg) once or twice daily for 12 weeks 1, 2
• Second-line (if no response at 12 weeks): Clindamycin 300 mg twice daily with rifampicin 600 mg once daily (or 300 mg twice daily) for 10-12 weeks 1, 2
• Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 2
• Assess response at 12 weeks using pain VAS, quality of life, lesion count, and number of flares 1

Severe Disease (Hurley Stage III)

• First-line biologic: Adalimumab is the only FDA-approved treatment for moderate to severe hidradenitis suppurativa in patients 12 years and older 4

Adult dosing: 4

• Day 1: 160 mg (given in one day or split over two consecutive days)
• Day 15: 80 mg
• Day 29 and subsequent doses: 40 mg every week OR 80 mg every other week

Adolescent dosing (12 years and older): 4

• Weight 30-60 kg: Day 1: 80 mg, then 40 mg every other week starting Day 8
• Weight ≥60 kg: Same as adult dosing

• If no clinical response after 16 weeks of adalimumab, consider alternative treatments 5
• Second-line biologic: Infliximab 5 mg/kg at weeks 0,2,6, and every 2 months thereafter for 12 weeks 2

Refractory Disease (Failed Biologics)

• Acitretin 0.3-0.5 mg/kg/day (for males and non-fertile females only) 1
• Dapsone (starting at 50 mg daily, titrating up to 200 mg daily) 2
• Ertapenem 1g daily for 6 weeks as rescue therapy 2

Surgical Management

• Deroofing procedure: For recurrent nodules and tunnels 2, 3
• Radical surgical excision: For extensive disease with sinus tracts and scarring, especially Hurley stage III 1, 2
• Healing options include secondary intention, skin grafts, thoracodorsal artery perforator (TDAP) flaps, or other reconstructive methods 1, 2
• Refer to hidradenitis suppurativa surgical multidisciplinary team for extensive excision 1
• Critical caveat: Non-surgical methods rarely result in lasting cure for advanced disease 2

Essential Adjunctive Therapies (For All Patients)

• Provide dressings for pus-producing lesions 1
• Pain management with NSAIDs for symptomatic relief 1, 3
• Smoking cessation referral (smoking has odds ratio of 3.6 for disease) 1, 3
• Weight management referral for patients with obesity (obesity has odds ratio of 3.3) 1, 3
• Screen and treat depression/anxiety 1
• Screen for cardiovascular risk factors given nearly doubled risk of cardiovascular-associated death 1

Monitoring Treatment Response

• Assess response at 12 weeks using Hidradenitis Suppurativa Clinical Response (HiSCR), which measures reduction in inflammatory lesions 2, 3, 5
• Monitor pain VAS and DLQI scores 1, 3
• Document lesion count and flare frequency 1

Critical Safety Warnings for Adalimumab

• Black box warning: Increased risk of serious infections (tuberculosis, bacterial sepsis, invasive fungal infections) leading to hospitalization or death 4
• Black box warning: Lymphoma and other malignancies, some fatal, reported in children and adolescents treated with TNF blockers 4
• Perform latent tuberculosis testing before initiating adalimumab; if positive, start TB treatment prior to adalimumab 4
• Monitor all patients for active tuberculosis during treatment, even if initial test negative 4
• Discontinue adalimumab if patient develops serious infection or sepsis 4

Treatments NOT Recommended

• The British Association of Dermatologists states insufficient evidence for: alitretinoin, anakinra, apremilast, azathioprine, ciclosporin, methotrexate, oral prednisolone, ustekinumab, secukinumab, and numerous other therapies 2
• Cryotherapy and microwave ablation are not recommended for acute phase lesions 2