What is the management approach for Hidradenitis suppurativa?

Management of Hidradenitis Suppurativa

For mild disease (Hurley Stage I), start with topical clindamycin 1% twice daily for 12 weeks; for moderate disease (Hurley Stage II), use clindamycin 300 mg plus rifampicin 600 mg orally daily for 10-12 weeks; for severe disease (Hurley Stage III) or failure of antibiotics, initiate adalimumab with loading doses of 160 mg, then 80 mg two weeks later, followed by 40 mg weekly. 1, 2, 3

Initial Assessment and Staging

• Document Hurley stage at baseline by examining all intertriginous areas (axillae, groin, inframammary, perianal) to determine total disease burden 1, 2
• Measure baseline pain using Visual Analog Scale (VAS) and count inflammatory lesions (nodules, abscesses, draining tunnels) 1, 2
• Screen for critical comorbidities: depression/anxiety, diabetes, hypertension, hyperlipidemia, inflammatory bowel disease (especially if persistent GI symptoms present), and inflammatory arthritis 1
• Refer immediately to dermatology for Hurley Stage III disease 1

Treatment Algorithm by Disease Severity

Hurley Stage I (Mild Disease)

Topical clindamycin 1% solution or gel 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 2, 4
• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) provides rapid relief within 1 day for acutely inflamed nodules 2, 4
• Reassess at 12 weeks using pain VAS, inflammatory lesion count, and Dermatology Life Quality Index (DLQI) 1, 2

Hurley Stage II (Moderate Disease)

First-line: Oral tetracycline 500 mg twice daily OR doxycycline 100 mg once or twice daily for 12-16 weeks 1, 2

• If inadequate response after 12 weeks, escalate to clindamycin 300 mg twice daily PLUS rifampicin 600 mg once daily for 10-12 weeks 1, 2
• This combination achieves 71-93% response rates, far superior to tetracycline monotherapy 2
• Do not use doxycycline as first-line for deep inflammatory lesions or abscesses as it has minimal effect on these lesions 2
• Treatment can be repeated intermittently; consider treatment breaks to assess ongoing need and limit antimicrobial resistance 1

Hurley Stage III (Severe Disease) or Refractory Cases

Adalimumab (FDA-approved for HS in patients ≥12 years): 1, 2, 3

• Loading regimen: 160 mg on Day 1 (single dose or split over two consecutive days), 80 mg on Day 15, then 40 mg weekly starting Day 29 1, 2, 3
• Monitor response using HiSCR (Hidradenitis Suppurativa Clinical Response: ≥50% reduction in inflammatory lesion count with no increase in abscesses or draining fistulas) 2, 5
• If no clinical response by 16 weeks, consider alternative biologics 2, 5

Second-line biologic: Infliximab 5 mg/kg at weeks 0,2,6, then every 8 weeks for adalimumab failures 2

Alternative systemic options for biologic-refractory disease: 1, 2

• Acitretin 0.3-0.5 mg/kg/day (males and non-fertile females only)
• Dapsone 50-200 mg daily (titrate gradually)

Surgical Management

Assess need for surgery in all patients based on presence of sinus tracts, scarring, and treatment response 1

• Deroofing: For recurrent nodules and tunnels without extensive scarring 2, 4
• Wide local excision: For extensive disease with chronic sinus tracts and morbid scarring; width of excision influences therapeutic outcome 1, 2
• Healing options: Secondary intention, skin grafts, or flaps 2
• Laser therapy (1470 nm diode): Emerging minimally invasive option for tissue preservation in recurrent disease 6

Essential Adjunctive Measures (All Patients)

• Pain management: NSAIDs for symptomatic relief; consider opioids for severe acute flares 1, 7
• Wound care: Appropriate dressings for draining lesions (non-adherent, absorbent) 1, 8
• Smoking cessation referral: Tobacco use strongly associated with worse outcomes 1, 2, 5
• Weight management referral: Obesity increases disease severity; weight loss is adjunctive therapy 2, 4, 5
• Antiseptic washes: Chlorhexidine, benzoyl peroxide, or zinc pyrithione daily 2, 4

Special Population Considerations

Pregnancy

• Metformin is safe for anti-androgen therapy if needed 1
• Continue adalimumab throughout pregnancy if disease well-controlled 1
• Avoid oral erythromycin due to increased risk of elevated liver enzymes 1
• Consult pediatrician about timing of live vaccines in neonates with in-utero biologic exposure 1

Breastfeeding

• Biologics likely safe based on pharmacokinetics (large proteins poorly absorbed via GI tract) 1
• Limit doxycycline to 3 weeks maximum without repeating courses 1
• Exercise caution with clindamycin due to increased infant GI side effects 1

Hepatitis B/C

• Screen for hepatitis B and C prior to immunosuppressants or biologics 1
• Coordinate with hepatologist for HBsAg-positive patients requiring biologics 1
• Avoid methotrexate if hepatic impairment present 1
• Use ciprofloxacin or co-trimoxazole for systemic antibiotics if cirrhosis present 1

Tuberculosis Screening

• Screen for latent TB with TST and/or IGRA before biologics; IGRA preferred in BCG-vaccinated populations 1
• Start prophylactic antibiotics at least 1 month before anti-TNF initiation for latent TB not at high risk 1
• Complete prophylactic antibiotics before anti-TNF initiation for latent TB at high risk or from endemic areas 1

Critical Pitfalls to Avoid

• Do not continue antibiotics beyond 4 months without reassessment to prevent antimicrobial resistance 2
• Do not use topical clindamycin alone long-term without combining with benzoyl peroxide due to resistance risk 2, 4
• Do not delay surgical evaluation in patients with established sinus tracts and scarring, as medical therapy alone will not resolve fibrotic lesions 7, 9
• Do not use cryotherapy or microwave ablation for acute lesions 1
• Do not prescribe oral contraceptives or spironolactone to males or use acitretin in females of childbearing potential without reliable contraception 1

Monitoring and Follow-Up

• Reassess at 12 weeks using pain VAS, inflammatory lesion count, and DLQI 1, 2
• For adalimumab therapy, monitor HiSCR at 16 weeks 2, 5
• Long-term monitoring for cutaneous squamous cell carcinoma, fistulating GI disease, inflammatory arthritis, genital lymphoedema, and anemia in moderate-to-severe chronic disease 1