What are the treatment options for Hidradenitis suppurativa?

Treatment Options for Hidradenitis Suppurativa

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

Disease Severity Assessment

• Determine disease severity using the Hurley staging system before initiating treatment 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 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 (nodules, abscesses, draining tunnels) 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. 1, 3, 2

• Combine topical clindamycin with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 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

• Alternative topical agents include resorcinol 15% cream, though irritant dermatitis is a common side effect 1

Moderate Disease (Hurley Stage II)

First-line systemic therapy is oral tetracyclines: doxycycline 100 mg once or twice daily OR tetracycline 500 mg twice daily for 12-16 weeks. 1, 3

• Lymecycline 408 mg once or twice daily for 12 weeks is an alternative first-line option 1

If inadequate response after 12 weeks of tetracyclines, escalate to second-line combination therapy: clindamycin 300 mg twice daily PLUS rifampicin 300-600 mg daily for 10-12 weeks. 1, 3

• The clindamycin-rifampicin combination demonstrates response rates of 71-93% in systematic reviews, far superior to tetracycline monotherapy 1

• This regimen can be repeated intermittently as needed 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 FDA-approved dosing: 1, 3, 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 1, 4

• Adolescents 12 years and older weighing 30-60 kg: 80 mg on Day 1, then 40 mg every other week starting Day 8 4

• Adolescents 12 years and older weighing ≥60 kg: Adult dosing (160 mg Day 1,80 mg Day 15, then 40 mg weekly or 80 mg every other week starting Day 29) 4

• Assess treatment response at 16 weeks using Hidradenitis Suppurativa Clinical Response (HiSCR), which measures ≥50% reduction in inflammatory lesions 1, 2

• If no clinical response after 16 weeks, consider alternative treatments 1, 2

Second-line biologic therapy is infliximab 5 mg/kg at weeks 0,2,6, and every 2 months thereafter for patients who fail adalimumab. 1

• Higher doses and more frequent intervals are supported for severe refractory cases 1

Alternative systemic options for patients unresponsive to adalimumab: 1

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

Surgical Interventions

Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring. 1, 2

• Deroofing: For recurrent nodules and tunnels without extensive scarring 1, 3

• Radical surgical excision: For extensive disease with sinus tracts and scarring 1, 3

  • Width of excision influences therapeutic outcome 1
  • Wound closure options include secondary intention healing, skin grafts, TDAP flap, or other reconstructive methods 1

• Non-surgical methods rarely result in lasting cure for advanced disease 1

Adjunctive Therapies and Comorbidity Management

All patients require screening and management of associated conditions: 1

• Screen for depression and anxiety 1

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

• Screen for inflammatory bowel disease, metabolic syndrome, and inflammatory arthritis 1, 5

Lifestyle modifications are essential adjuncts: 1, 2

• Smoking cessation referral (tobacco use associated with worse outcomes) 1, 2

• Weight loss for patients with obesity (obesity increases disease severity) 1, 3, 2

• Pain management with NSAIDs for symptomatic relief 1, 2

• Appropriate wound dressings for draining lesions 1, 2

Monitoring Treatment Response

• Reassess at 12 weeks using HiSCR (≥50% reduction in inflammatory lesions), pain VAS score, and Dermatology Life Quality Index (DLQI) 1, 2

• For adalimumab specifically, assess response at 16 weeks 1, 2

• Discontinue ulcerative colitis-indication adalimumab dosing if no clinical remission by 8 weeks (Day 57), though this does not apply to HS indication 4

Common Pitfalls and Caveats

• Do not use doxycycline as first-line for Hurley Stage II with deep inflammatory lesions or abscesses, as it has minimal effect on these lesions; use clindamycin-rifampicin instead 1

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

• Topical clindamycin monotherapy may increase Staphylococcus aureus resistance; always combine with benzoyl peroxide to reduce this risk 1

• Avoid cryotherapy and microwave ablation during acute phase, as these are not recommended 1

• Numerous therapies lack sufficient evidence and should not be routinely used, including: alitretinoin, anakinra, apremilast, azathioprine, ciclosporin, colchicine, methotrexate, oral prednisolone, phototherapy, and ustekinumab 1

• Adalimumab carries boxed warnings for serious infections (including tuberculosis) and malignancy, particularly hepatosplenic T-cell lymphoma in adolescents and young adults with inflammatory bowel disease receiving concomitant azathioprine or 6-mercaptopurine 4

• Perform latent TB testing before starting adalimumab; if positive, treat TB before initiating biologic therapy 4