What is the management for hidradenitis suppurativa?

Management of Hidradenitis Suppurativa

Treatment of hidradenitis suppurativa should follow a severity-based algorithmic approach using Hurley staging, with topical clindamycin for mild disease, combination oral antibiotics for moderate disease, and adalimumab for severe or refractory cases, often requiring surgical intervention for lasting cure. 1, 2

Initial Assessment and Diagnosis

• Diagnosis requires three clinical findings: (1) typical HS lesions (painful nodules, abscesses, draining tunnels), (2) characteristic locations (axillae, inguinal, genitoanal, or inframammary areas), and (3) recurrence 1
• Assess disease severity using the Hurley staging system to guide treatment selection 1, 2
• Measure baseline pain using Visual Analog Scale and quality of life using Dermatology Life Quality Index (DLQI) 1, 2
• Screen for comorbidities including depression/anxiety, diabetes (HbA1c), cardiovascular risk factors (BP, lipids), inflammatory bowel disease, and metabolic syndrome 2, 3

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I)

First-line therapy is topical clindamycin 1% solution or gel applied twice daily for 12 weeks. 1, 2

• Combine with antiseptic skin cleansers (chlorhexidine, benzoyl peroxide, or zinc pyrithione) to reduce bacterial load 2
• Critical pitfall: Topical clindamycin monotherapy may increase Staphylococcus aureus resistance; consider combining with benzoyl peroxide to mitigate this risk 2
• For inflamed lesions, inject intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion), which significantly reduces erythema, edema, suppuration, and pain 2
• Resorcinol 15% cream can reduce pain and abscess duration, though irritant dermatitis is common 2

Moderate Disease (Hurley Stage II)

First-line systemic therapy is oral tetracycline 500 mg twice daily OR doxycycline 100 mg once or twice daily for up to 4 months. 1, 2

Second-line therapy is clindamycin 300 mg orally twice daily combined with rifampicin 300-600 mg daily for 10-12 weeks. 1, 2, 4

• The clindamycin-rifampicin combination provides superior efficacy for moderate disease with abscesses compared to tetracyclines alone 4
• Critical dosing requirement: Clindamycin must be 300 mg twice daily (not lower) and rifampicin must be 300-600 mg daily for systemic effect 4
• Consider treatment breaks after completing antibiotic courses to assess ongoing need and limit antimicrobial resistance 2, 4
• If no response after 12 weeks, escalate to triple therapy with moxifloxacin + metronidazole + rifampin OR consider biologics 4

Severe Disease (Hurley Stage III) or Refractory Moderate Disease

First-line biologic therapy is adalimumab with the following FDA-approved dosing: 5

Adults:

• Day 1: 160 mg (given in one day or split over two consecutive days)
• Day 15: 80 mg
• Day 29 and ongoing: 40 mg weekly OR 80 mg every other week 5

Adolescents 12 years and older: 5

• Weight 30-60 kg: Day 1: 80 mg, then 40 mg every other week starting Day 8

• Weight ≥60 kg: Same as adult dosing

• Critical pitfall: Adalimumab 40 mg every other week is insufficient dosing and not recommended for HS 2

• Assess treatment response at 16 weeks; if no clinical response, consider alternative therapies 2

• Monitor for serious infections and malignancies, particularly in adolescents and young adults 5

Alternative biologic options for adalimumab failures: 1, 2

• Infliximab 5 mg/kg at weeks 0,2,6, then every 2 months for 12 weeks 1, 2
• Secukinumab and bimekizumab (IL-17 inhibitors) are newer approved options 3

Non-biologic alternatives for severe disease: 2

• Acitretin 0.3-0.5 mg/kg/day 2
• Dapsone starting at 50 mg daily, titrating up to 200 mg daily 2
• Ertapenem 1 g IV daily for 6 weeks as rescue therapy or during surgical planning 2

Surgical Management

Surgery is often necessary for lasting cure, particularly in advanced disease with sinus tracts and scarring. 1, 2

• Deroofing procedure: For recurrent nodules and tunnels without extensive scarring 2
• Radical surgical excision: For extensive disease with sinus tracts and scarring; the width of excision influences therapeutic outcome 2
• Wound closure options include secondary intention healing, skin grafts, or flaps (including TDAP flap) 2
• Critical principle: Non-surgical methods rarely result in lasting cure for advanced disease 2
• Medical optimization before surgery improves outcomes 6

Adjunctive Therapies (Essential for All Patients)

• Pain management: NSAIDs for symptomatic relief 2
• Wound care: Appropriate dressings for draining lesions 2, 4
• Weight loss: Strongly encourage for patients with obesity, as it improves outcomes 1, 2
• Smoking cessation: Tobacco use is associated with worse outcomes and must be addressed 1, 2
• Screen and treat depression/anxiety: HS profoundly impacts quality of life 2, 3

Monitoring Treatment Response

• Assess response at 12 weeks using Hidradenitis Suppurativa Clinical Response (HiSCR), which measures reduction in inflammatory lesions 2
• Re-evaluate pain scores and DLQI at each visit 1, 2
• For adalimumab, discontinue if no clinical remission by 16 weeks 2

Therapies with Insufficient Evidence

The following therapies lack sufficient evidence and are NOT recommended: 2

• Alitretinoin, anakinra, apremilast, azathioprine, ciclosporin, colchicine, finasteride, methotrexate, oral prednisolone, spironolactone, ustekinumab, laser/photodynamic therapies, hyperbaric oxygen, and radiotherapy 2
• Avoid cryotherapy and microwave ablation during acute phase 2

Special Populations

• Pediatric patients 6-11 years with moderate-severe disease: Use weight-based dosing for systemic antibiotics; doxycycline is recommended for children ≥8 years 2
• Pediatric patients ≥12 years: Adalimumab is FDA-approved using weight-based dosing 5