What is the recommended treatment for a patient with suspected Hidradenitis Suppurativa (HS), including dosage and duration?

Treatment Approach for Suspected Hidradenitis Suppurativa

For suspected HS with drainage, initiate topical clindamycin 1% solution twice daily combined with benzoyl peroxide or chlorhexidine wash, and simultaneously start oral doxycycline 100 mg twice daily or lymecycline 408 mg once or twice daily for 12 weeks. 1, 2

Initial Assessment and Confirmation

Before finalizing treatment, confirm the diagnosis and assess disease extent:

• Examine all intertriginous areas (axillary vaults, gluteal cleft, groin, inframammary regions) to determine Hurley stage and total disease burden 1
• Document baseline pain using Visual Analog Scale (VAS) and inflammatory lesion count 1
• Screen for comorbidities: depression/anxiety, diabetes, hypertension, hyperlipidemia, inflammatory bowel disease 1

The presence of drainage strongly suggests HS over verruca, as drainage indicates deeper inflammatory lesions or sinus tract formation characteristic of at least Hurley stage II disease 1, 3

Topical Therapy Regimen

Topical clindamycin 1% solution applied twice daily to all affected areas for 12 weeks 1, 2

• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 1, 4
• Benzoyl peroxide is preferred over chlorhexidine as it specifically reduces antibiotic resistance when combined with clindamycin 1, 4
• Topical clindamycin alone reduces pustules but has minimal effect on inflammatory nodules and abscesses 1

Systemic Antibiotic Therapy

First-Line Oral Antibiotics (12 weeks minimum)

Tetracycline class antibiotics:

• Doxycycline 100 mg once or twice daily for 12-16 weeks 1, 2
• Lymecycline 408 mg once or twice daily for 12 weeks 1
• Tetracycline 500 mg twice daily for up to 4 months 1, 2

These agents work through anti-inflammatory properties rather than antimicrobial effects 1, 5

Second-Line Combination Therapy (if no response at 12 weeks)

Clindamycin 300 mg twice daily PLUS rifampicin 300-600 mg daily (typically 300 mg twice daily) for 10-12 weeks 1, 2

• This combination achieves 71-93% response rates in systematic reviews, far superior to tetracycline monotherapy 1, 2
• Treatment duration is specifically 8-12 weeks and can be repeated intermittently 1, 2
• This regimen is the preferred first-line choice for Hurley stage II disease with abscesses and inflammatory nodules 1, 2

Treatment Assessment and Escalation

Reassess at 12 weeks using:

• Pain VAS score 1
• Inflammatory lesion count 1
• Quality of life measures (DLQI) 1

If Inadequate Response After 12 Weeks of Tetracyclines:

Escalate to clindamycin 300 mg + rifampicin 300 mg twice daily for 10-12 weeks 1, 2

If Inadequate Response After Clindamycin-Rifampicin:

Consider third-line triple therapy (typically reserved for bridging to surgery or biologics):

• Moxifloxacin 400 mg once daily
• Metronidazole 500 mg three times daily (stop at 6 weeks to avoid neurologic toxicity)
• Rifampicin 300 mg twice daily
• Duration: 1-12 months 1

If Still Inadequate Response:

Adalimumab (biologic therapy):

• Week 0: 160 mg (single dose or split over 2 consecutive days)
• Week 2: 80 mg
• Week 4 onward: 40 mg weekly 1, 2, 6, 7

This is FDA-approved for moderate-to-severe HS in patients ≥12 years old 7

Adjunctive Measures

Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) for acutely inflamed nodules provides rapid symptom relief within 1 day but does not address underlying disease 1, 2, 8

Essential lifestyle modifications:

• Smoking cessation referral (smoking has odds ratio of 3-6 for HS) 1
• Weight management referral if BMI elevated 1
• Appropriate wound dressings for draining lesions 1
• Pain management with NSAIDs 1

Critical Pitfalls to Avoid

• Do not use topical clindamycin as monotherapy beyond 12 weeks without adding benzoyl peroxide, as it significantly increases S. aureus resistance 1, 4
• Do not continue doxycycline monotherapy beyond 4 months without reassessment, as it has minimal effect on deep inflammatory lesions and increases resistance risk 2
• Do not use adalimumab 40 mg every other week (the standard dosing for other conditions) as this is ineffective for HS; weekly dosing is required 1, 7
• Do not delay surgical referral for Hurley stage III disease with extensive sinus tracts and scarring, as medical therapy alone rarely achieves lasting cure 1, 3, 9

Treatment Duration Summary

• Topical clindamycin + benzoyl peroxide: 12 weeks initially, can continue long-term 1, 4
• Oral tetracyclines: 12-16 weeks (up to 4 months maximum) 1, 2
• Clindamycin + rifampicin: 10-12 weeks, repeatable intermittently 1, 2
• Triple antibiotic therapy: 1-12 months (stop metronidazole at 6 weeks) 1
• Adalimumab: Ongoing weekly maintenance after loading doses 7