What are the treatment options for Hidradenitis suppurativa?

Hidradenitis Suppurativa Treatment

Treatment of hidradenitis suppurativa follows a severity-based stepwise approach: topical clindamycin 1% for mild disease, oral antibiotics (clindamycin plus rifampicin) for moderate disease, and adalimumab for severe or refractory cases, with surgery reserved for extensive fibrotic disease. 1, 2

Disease Severity Assessment

• Determine disease severity using the Hurley staging system before initiating treatment 1, 3
  • 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 abscesses across entire anatomic area 1
• Examine all intertriginous areas (axillae, groin, inframammary, perianal) to determine total disease burden 1
• Document baseline pain using Visual Analog Scale (VAS) and count inflammatory lesions 1
• Screen for comorbidities: depression/anxiety, diabetes, hypertension, hyperlipidemia, and inflammatory bowel disease 1

Mild Disease (Hurley Stage I)

First-Line Topical Therapy

• Topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks 1, 2, 3
• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 1
• Alternative adjunctive cleansers include zinc pyrithione 1

Adjunctive Treatments for Inflamed Lesions

• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) for acutely inflamed nodules provides rapid symptom relief within 1 day 1
• Resorcinol 15% cream can reduce pain and duration of abscesses, though irritant dermatitis is a common side effect 1

Oral Antibiotics for Widespread Mild Disease

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

Moderate Disease (Hurley Stage II)

First-Line Systemic Therapy

• Clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily (once or twice daily) for 10-12 weeks 1, 2
• This combination demonstrates response rates of 71-93% in systematic reviews, far superior to tetracycline monotherapy 1
• Treatment can be repeated intermittently as monotherapy or as adjuvant therapy in severe disease 1

Treatment Assessment at 12 Weeks

• Reassess using pain VAS score, inflammatory lesion count, and Dermatology Life Quality Index (DLQI) 1
• If inadequate response after 12 weeks of tetracyclines, escalate to clindamycin plus rifampicin 1
• Consider treatment break after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1

Alternative Options for Antibiotic Failures

• Dapsone starting at 50 mg daily, titrating up to 200 mg daily 1
• Ertapenem 1g daily for 6 weeks as rescue therapy or during surgical planning for severe disease requiring IV antibiotics 1

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

First-Line Biologic Therapy: Adalimumab

• Adalimumab dosing schedule 1, 2, 4:
  • Adults: 160 mg at week 0 (single dose or split over two consecutive days), 80 mg at week 2, then 40 mg weekly starting at week 4
  • Adolescents 12 years and older:
    • 30-60 kg: 80 mg day 1, then 40 mg every other week starting day 8
    • ≥60 kg: 160 mg day 1 (single dose or split over two days), 80 mg day 15, then 40 mg weekly or 80 mg every other week starting day 29
• Adalimumab is FDA-approved for moderate to severe hidradenitis suppurativa in patients 12 years and older 4
• Assess treatment response at 16 weeks; if no clinical response, consider alternative treatments 1, 3

Second-Line Biologic Therapy

• Infliximab 5 mg/kg at weeks 0,2,6, and every 2 months thereafter for 12 weeks for patients who fail adalimumab 1
• Higher doses and more frequent intervals supported for severe refractory cases 1

Alternative Systemic Options

• Acitretin 0.3-0.5 mg/kg/day for patients unresponsive to adalimumab 1
• Secukinumab for patients 6 years and older with treatment-refractory disease, with response rates of 64.5-71.4% in adalimumab-failure patients at 16-52 weeks 1

Surgical Interventions

Indications for Surgery

• Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring 1, 5
• Non-surgical methods rarely result in lasting cure for advanced disease 1

Surgical Options

• Deroofing for recurrent nodules and tunnels 1, 2
• Radical surgical excision for extensive disease with sinus tracts and scarring 1, 2
• Wound closure options include secondary intention healing, skin grafts, or flaps (TDAP flap or other reconstructive methods) 1
• Width of excision influences therapeutic outcome 1

Adjunctive Therapies and Lifestyle Modifications

Essential Lifestyle Interventions

• Smoking cessation referral - tobacco use is associated with worse outcomes 1, 3
• Weight loss for patients with obesity - obesity is associated with increased disease severity 2, 3
• Pain management with NSAIDs for symptomatic relief 1, 3
• Appropriate wound dressings for draining lesions 1, 3

Comorbidity Screening and Management

• Screen for cardiovascular risk factors: measure blood pressure, lipids, and HbA1c 1
• Screen for depression and anxiety 1

Treatment Monitoring

• Use Hidradenitis Suppurativa Clinical Response (HiSCR) to measure reduction in inflammatory lesions 1, 3
• Assess treatment response after 12 weeks using HiSCR and patient-reported outcomes 1
• Monitor quality of life improvement using DLQI 1

Treatments NOT Recommended

The British Journal of Dermatology states there is insufficient evidence to recommend: alitretinoin, anakinra, apremilast, atorvastatin, azathioprine, ciclosporin, colchicine, cyproterone, finasteride, fumaric acid esters, hydrocortisone, hyperbaric oxygen therapy, intravenous antibiotics, isoniazid, laser and photodynamic therapies, methotrexate, oral prednisolone, oral zinc, phototherapy, photochemotherapy, radiotherapy, secukinumab, spironolactone, staphage lysate, tolmetin sodium, and ustekinumab 1

Cryotherapy and microwave ablation are recommended against for treating lesions during the acute phase 1

Common Pitfalls

• Do not use doxycycline as first-line for Hurley Stage II with deep inflammatory lesions or abscesses - it has minimal effect on these lesions; clindamycin plus rifampicin is superior 1
• Do not continue doxycycline beyond 4 months without reassessment - prolonged use increases antimicrobial resistance risk without proven additional benefit 1
• Topical clindamycin monotherapy may increase rates of Staphylococcus aureus resistance - combine with benzoyl peroxide to reduce this risk 1
• Do not delay escalation to biologics in severe disease - early aggressive treatment prevents irreversible skin damage with tunnel formation and morbid scarring 6