What are the treatments for hidradenitis suppurativa?

Treatment of Hidradenitis Suppurativa

Treatment of hidradenitis suppurativa follows a severity-based algorithm: topical clindamycin 1% twice daily for 12 weeks for mild disease (Hurley Stage I), clindamycin 300 mg plus rifampicin 300-600 mg orally twice daily for 10-12 weeks for moderate disease (Hurley Stage II), and adalimumab 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting week 4 for severe or refractory disease (Hurley Stage III). 1, 2, 3

Disease Severity Assessment

Before initiating treatment, determine disease severity using the Hurley staging system 1, 2:

• Hurley Stage I: Isolated nodules and abscesses without sinus tracts or scarring 1
• Hurley Stage II: Recurrent abscesses with sinus tract formation and scarring, separated by normal skin 1
• Hurley Stage III: Diffuse involvement with multiple interconnected sinus tracts and scarring 1

Examine all intertriginous areas (axillae, groin, inframammary, perianal) to assess total disease burden 1. Document baseline pain using Visual Analog Scale and count inflammatory lesions 1.

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I)

First-line therapy is topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks. 4, 1, 2

Combine topical clindamycin with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk. 1 Topical clindamycin monotherapy increases rates of bacterial resistance, making combination therapy essential 1.

For acutely inflamed nodules, inject intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) to provide rapid symptom relief within 1 day. 1 This shows significant reduction in erythema, edema, suppuration, and pain 1.

Alternative topical options include resorcinol 15% cream, which reduces pain and abscess duration, though irritant dermatitis is common 1, 5.

Moderate Disease (Hurley Stage II)

First-line therapy is clindamycin 300 mg orally twice daily plus rifampicin 300-600 mg orally once or twice daily for 10-12 weeks. 4, 1, 2 This combination demonstrates response rates of 71-93% in systematic reviews, far superior to monotherapy 1.

Alternative first-line options for more widespread mild disease include 4, 1:

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

However, doxycycline monotherapy is not independently linked to better outcomes for Hurley Stage II disease and should not be used as first-line for deep inflammatory lesions or abscesses. 1 The clindamycin-rifampicin combination is superior for abscesses and inflammatory nodules characteristic of Hurley Stage II 1.

Reassess treatment response at 12 weeks using pain scores, inflammatory lesion count, and quality of life measures (DLQI). 1 Consider a treatment break after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1.

Severe or Refractory Disease (Hurley Stage III or Failed Antibiotics)

First-line biologic therapy is adalimumab with the following dosing schedule: 4, 1, 2, 3

• Week 0: 160 mg (given in one day or split over two consecutive days)
• Week 2: 80 mg
• Week 4 and beyond: 40 mg weekly

Adalimumab 40 mg every other week is insufficient dosing and should not be used. 2 The FDA-approved weekly dosing is required for hidradenitis suppurativa 3.

Adalimumab demonstrates HiSCR (Hidradenitis Suppurativa Clinical Response) rates of 42-59% at week 12 compared to 26-28% for placebo 6. The number needed to treat is 4, with a favorable benefit-risk ratio 6.

Monitor treatment response at 12 weeks using HiSCR (≥50% reduction in inflammatory lesion count), pain VAS, and DLQI. 1, 2, 6 Note that 40% of initial non-responders may achieve response by week 36 with continued treatment 6. However, almost half of week 12 responders lose response by week 36 despite continued weekly dosing 6.

If adalimumab fails after 16 weeks, escalate to infliximab 5 mg/kg at weeks 0,2,6, and every 2 months thereafter. 1, 2 Higher doses and more frequent intervals are supported for severe refractory cases 1.

Secukinumab is an alternative for adalimumab-failure patients, with response rates of 64.5-71.4% at 16-52 weeks. 1 Dual biologic therapy combining secukinumab with infliximab targets different inflammatory pathways and is supported for treatment-refractory disease 1.

Alternative systemic options for patients unresponsive to adalimumab include 1:

• Acitretin 0.3-0.5 mg/kg/day
• Dapsone 50-200 mg daily (start at 50 mg and titrate)
• Ertapenem 1 g IV daily for 6 weeks (rescue therapy or during surgical planning)

Surgical Interventions

Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring. 4, 1, 2 Non-surgical methods rarely result in lasting cure for advanced disease 1.

Surgical options based on disease extent 4, 1, 2:

• Deroofing: For recurrent nodules and tunnels without extensive scarring 1
• Radical surgical excision: For extensive Hurley Stage III disease with multiple sinus tracts and scarring 4, 1, 2
• Wound closure options: Secondary intention healing, skin grafts, TDAP flap, or other reconstructive methods 1

The width of excision influences therapeutic outcome 1. Assess need for surgical intervention in all patients depending on type and extent of scarring 4.

Special Populations

For adolescents 12 years and older with moderate to severe disease, adalimumab is FDA-approved with weight-based dosing: 1, 3

• 30-60 kg: Day 1: 80 mg; Day 8 and beyond: 40 mg every other week
• ≥60 kg: Adult dosing (160 mg → 80 mg → 40 mg weekly)

For children 8 years and older requiring systemic antibiotics, oral doxycycline is recommended. 1

For pregnant patients: 2

• Requiring anti-androgens: Metformin
• Requiring biologics: Adalimumab

Adjunctive Therapies and Comorbidity Management

Screen all patients for: 1, 2

• Depression and anxiety
• Cardiovascular risk factors (blood pressure, lipids, HbA1c)
• Diabetes mellitus
• Inflammatory bowel disease

Essential lifestyle modifications include: 1, 2

• Smoking cessation referral (tobacco use associated with worse outcomes)
• Weight loss for patients with obesity
• Wearing loose-fitting clothes
• Appropriate wound dressings for draining lesions
• Pain management with NSAIDs for symptomatic relief

Treatments NOT Recommended

The following therapies have insufficient evidence or are contraindicated: 1, 2

• Isotretinoin (unless concomitant moderate-to-severe facial/truncal acne)
• Etanercept
• Adalimumab 40 mg every other week (insufficient dosing)
• Cryotherapy during acute phase (causes excessive pain)
• Microwave ablation
• Alitretinoin, anakinra, apremilast, azathioprine, ciclosporin, colchicine, methotrexate, oral prednisolone, phototherapy, radiotherapy, ustekinumab

Critical Pitfalls to Avoid

Do not continue doxycycline beyond 4 months without reassessment, as prolonged use increases antimicrobial resistance without proven additional benefit. 1

Do not use topical clindamycin without combining with benzoyl peroxide or chlorhexidine, as this increases S. aureus resistance. 1

Do not use doxycycline monotherapy as first-line for Hurley Stage II disease with abscesses or deep inflammatory lesions—it has minimal effect on these lesions. 1

If no clinical response after 12 weeks of initial therapy, escalate treatment rather than continuing ineffective therapy. 1 For failed tetracyclines, escalate to clindamycin-rifampicin; for failed clindamycin-rifampicin, escalate to adalimumab 4, 1.