What is the treatment for hydradenitis?

Treatment of Hidradenitis Suppurativa

Disease Severity Assessment

Begin by determining Hurley stage through examination of all intertriginous areas (axillae, groin, inframammary, perianal) to assess for nodules, abscesses, sinus tracts, and scarring. 1

• Hurley Stage I: Isolated nodules/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

Document baseline pain using Visual Analog Scale and inflammatory lesion count to track treatment response 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. 2, 1

• Combine with antiseptic washes (chlorhexidine 4%, benzoyl peroxide, or zinc pyrithione) daily to reduce bacterial load and prevent Staphylococcus aureus resistance 2, 1
• For acutely inflamed nodules, inject intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion), which provides rapid symptom relief within 1 day with significant reduction in erythema, edema, suppuration, and pain 2, 1
• Apply warm compresses to inflamed lesions 2

If inadequate response after 12 weeks, escalate to oral tetracyclines: doxycycline 100 mg once or twice daily OR lymecycline 408 mg once or twice daily for 12 weeks 2, 1

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. 2, 1, 3

• This combination demonstrates response rates of 71-93% and is superior to tetracycline monotherapy for abscesses and inflammatory nodules 1
• Critical dosing: Ensure rifampicin is 300-600 mg daily (not lower) and clindamycin is 300 mg twice daily—underdosing is a common cause of treatment failure 4, 3
• This regimen can be repeated intermittently after treatment breaks 2, 1

If no response after 12 weeks, escalate to triple therapy: moxifloxacin + metronidazole + rifampin 4, 3

Alternative option: Ertapenem 1g IV daily for 6 weeks as rescue therapy for severe flares requiring intravenous antibiotics 1

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

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

• 160 mg subcutaneous at week 0
• 80 mg at week 2
• 40 mg weekly starting at week 4

If adalimumab fails after 16 weeks, second-line biologic is infliximab 5 mg/kg IV at weeks 0,2,6, then every 2 months. 2, 1

For patients who fail both adalimumab and infliximab, consider secukinumab (response rate 64.5-71.4% in adalimumab-failure patients) 1

Alternative non-biologic options for adalimumab-refractory patients: 2, 1

• Acitretin 0.3-0.5 mg/kg/day
• Dapsone 50-200 mg daily (start low and titrate)

Surgical Interventions

Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring. 1, 5

Surgical Options by Disease Extent

• For recurrent nodules and tunnels: Deroofing procedure 2, 1
• For extensive disease with sinus tracts and scarring: Radical surgical excision of all affected tissue 2, 1
• Wound closure options: Secondary intention healing (preferred for perianal disease), TDAP flap, skin grafts, or other reconstructive methods 2, 1, 5

Critical surgical pitfall: Avoid split-thickness skin grafts in the anal canal as they may contract and cause anal stenosis 5

Procedures to avoid: Do not offer cryotherapy or microwave ablation for acute lesions 2, 1

Simple incision and drainage should only be used for acute abscesses requiring immediate pain relief, as it is inadequate for long-term HS management 2, 4

Treatment Monitoring and Response Assessment

Reassess all patients at 12 weeks using: 2, 1

• Hidradenitis Suppurativa Clinical Response (HiSCR): ≥50% reduction in inflammatory lesion count
• Pain Visual Analog Scale score
• Dermatology Life Quality Index (DLQI)

After completing antibiotic courses, consider treatment breaks to assess need for ongoing therapy and limit antimicrobial resistance. 2, 1

Essential Adjunctive Measures

Comorbidity Screening (Mandatory for All Patients)

• Screen for depression and anxiety 2, 1
• Measure blood pressure, lipids, and HbA1c to assess cardiovascular risk factors 2, 1
• Screen for inflammatory bowel disease 1

Lifestyle Modifications

• Smoking cessation: Tobacco use has an odds ratio of 36 for HS 4
• Weight loss if obese: Obesity has an odds ratio of 33 for HS 4
• Pain management with NSAIDs for symptomatic relief 1, 4
• Appropriate wound dressings for draining lesions based on drainage amount and location 1, 4

Special Populations

Pediatric Patients

• For children ≥12 years with moderate-to-severe disease: Adalimumab is FDA-approved with weight-based dosing 1
• For children ≥8 years requiring systemic antibiotics: Oral doxycycline is recommended 1
• Goal is to minimize scarring, progression, and need for surgery 2

Pregnant Patients

• First-line: Topical treatments, procedural treatments, and lifestyle modifications 2
• Second-line: Systemic agents with careful consideration of FDA pregnancy recommendations 2
• Contraindicated: Retinoids, hormonal therapies, and certain immunosuppressants 2

Treatments with Insufficient Evidence

The British Association of Dermatologists states there is insufficient evidence to recommend: alitretinoin, anakinra, apremilast, atorvastatin, azathioprine, ciclosporin, colchicine, cyproterone, finasteride, fumaric acid esters, hyperbaric oxygen, intravenous antibiotics (except ertapenem), isoniazid, laser/photodynamic therapies, methotrexate, oral prednisolone, oral zinc, phototherapy, radiotherapy, spironolactone, tolmetin sodium, or ustekinumab 2, 1

Critical Pitfalls to Avoid

• Never use topical clindamycin monotherapy for moderate disease with abscesses—it increases Staphylococcus aureus resistance and is insufficient 4, 3
• Never continue antibiotics beyond 12-16 weeks without reassessment and treatment breaks—prolonged use increases antimicrobial resistance without proven additional benefit 1, 3
• Do not use doxycycline as first-line for Hurley Stage II with deep inflammatory lesions or abscesses—clindamycin plus rifampicin is superior 1, 3
• Avoid underdosing antibiotic regimens—this is a common cause of treatment failure 4, 3