Hidradenitis Suppurativa: Assessment and Treatment
Disease Severity Assessment
Begin by determining Hurley stage through examination of all intertriginous areas (axillae, groin, genitoanal, inframammary regions) to assess for nodules, abscesses, sinus tracts, and scarring. 1, 2
- Document baseline pain using Visual Analog Scale (VAS) and count inflammatory lesions 1
- Screen for comorbidities: depression/anxiety, diabetes, hypertension, hyperlipidemia, inflammatory bowel disease 1, 3
- Measure cardiovascular risk factors (blood pressure, lipids, HbA1c) 1
- Assess quality of life using Dermatology Life Quality Index (DLQI) 1
Treatment Algorithm by Disease Severity
Mild Disease (Hurley Stage I: Isolated nodules/abscesses without sinus tracts)
First-line: Topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks. 1, 3, 2
- Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 1, 3
- Alternative adjunctive cleansers: zinc pyrithione 1
- For acutely inflamed nodules: intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) provides rapid symptom relief within 1 day, significantly reducing erythema, edema, suppuration, and pain 1, 3
- Resorcinol 15% cream can reduce pain and abscess duration, though irritant dermatitis is common 1
Reassess at 12 weeks using pain VAS, inflammatory lesion count, and DLQI. 1 If inadequate response, escalate to moderate disease treatment.
Moderate Disease (Hurley Stage II: Recurrent nodules/abscesses with sinus tracts and scarring)
First-line: Oral tetracyclines for 12-16 weeks. 1, 3
- Doxycycline 100 mg once or twice daily for up to 4 months 1, 3
- Alternative: Lymecycline 408 mg once or twice daily for 12 weeks 1
- Alternative: Tetracycline 500 mg twice daily for up to 4 months 1
Critical pitfall: Do not use doxycycline monotherapy as first-line for Hurley Stage II with deep inflammatory lesions or abscesses—it has minimal effect on these lesions. 1 Response rates for doxycycline monotherapy are far inferior to combination therapy.
Second-line (preferred for Hurley Stage II): Clindamycin 300 mg twice daily PLUS rifampicin 300-600 mg daily for 10-12 weeks. 1, 3, 2
- This combination demonstrates response rates of 71-93% in systematic reviews, significantly superior to doxycycline monotherapy 1
- Treatment typically lasts 8-12 weeks and can be repeated intermittently 1
- This regimen is far superior for abscesses and inflammatory nodules characteristic of Hurley Stage II 1
Reassess at 12 weeks using Hidradenitis Suppurativa Clinical Response (HiSCR), which measures reduction in inflammatory lesions. 1, 3, 2 If no clinical response after 12 weeks, escalate to biologics or consider triple therapy (moxifloxacin + metronidazole + rifampin). 1
Take treatment breaks 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: Adalimumab with loading dose regimen. 1, 2, 4
- 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 (NOT every other week—insufficient dosing) 2
Adolescents 12 years and older: 1, 4
- 30-60 kg: Day 1: 80 mg; Day 8 and ongoing: 40 mg every other week
- ≥60 kg: Day 1: 160 mg; Day 15: 80 mg; Day 29 and ongoing: 40 mg weekly or 80 mg every other week
Assess response at 16 weeks using HiSCR. 1 If no clinical response by 16 weeks, consider alternative treatments. 1
Second-line biologic (for adalimumab failures): Infliximab 5 mg/kg at weeks 0,2,6, then every 2 months. 1, 3
- Higher doses and more frequent intervals are supported for severe refractory cases 1
- Secukinumab can be used in combination with infliximab for treatment-refractory disease, with response rates of 64.5-71.4% in adalimumab-failure patients at 16-52 weeks 1
Alternative systemic options for adalimumab non-responders: 1
- Acitretin 0.3-0.5 mg/kg/day
- Dapsone 50 mg daily, titrating up to 200 mg daily
- Ertapenem 1g daily for 6 weeks (rescue therapy or during surgical planning)
Surgical Interventions
Surgery is the only curative therapy for HS, especially necessary for lasting cure in advanced disease with sinus tracts and scarring. 1, 5, 6
Surgical options by disease extent: 1, 2
- Recurrent nodules and tunnels: Deroofing procedure
- Extensive disease with sinus tracts and scarring: Radical surgical excision (width of excision influences therapeutic outcome)
- Wound closure options: Secondary intention healing, skin grafts, TDAP flap, or other reconstructive methods
Consider extensive excision when conventional systemic treatments have failed. 2 Non-surgical methods rarely result in lasting cure for advanced disease. 1
Do NOT offer: 2
- Cryotherapy during acute phase (causes excessive pain)
- Microwave ablation
Essential Adjunctive Measures
Lifestyle modifications are critical and should be addressed at every visit: 1, 3
- Smoking cessation referral (tobacco associated with worse outcomes) 1, 3
- Weight loss referral if BMI elevated (obesity worsens disease) 1, 3
- Pain management with NSAIDs for symptomatic relief 1
- Appropriate wound dressings for draining lesions 1, 3
Special Populations
Pregnant patients: 2
- Requiring anti-androgens: Metformin
- Requiring biologics: Adalimumab
- Adalimumab FDA-approved for ages ≥12 years with moderate-to-severe disease (weight-based dosing)
- Doxycycline recommended for ages ≥8 years requiring systemic antibiotics
Treatments NOT Recommended (Insufficient Evidence)
The following therapies lack sufficient evidence and should NOT be routinely offered: 1
- Alitretinoin, anakinra, apremilast, atorvastatin, azathioprine, ciclosporin, colchicine, cyproterone, finasteride, fumaric acid esters, hyperbaric oxygen, intravenous antibiotics, isoniazid, laser/photodynamic therapies, methotrexate, oral prednisolone, oral zinc, phototherapy, photochemotherapy, radiotherapy, spironolactone, tolmetin sodium, ustekinumab
- Isotretinoin (unless concomitant moderate-to-severe acneiform lesions of face/trunk) 2
- Etanercept 2
- Adalimumab 40 mg every other week (insufficient dosing) 2
Monitoring Strategy
At 12-week intervals, assess: 1, 3
- HiSCR (reduction in inflammatory lesions)
- Pain VAS score
- DLQI (quality of life)
- Inflammatory lesion count
Do not continue doxycycline beyond 4 months without reassessment—prolonged use increases antimicrobial resistance without proven additional benefit. 1