What is the treatment for hidradenitis?

Treatment for Hidradenitis Suppurativa

For mild disease (Hurley Stage I), start with topical clindamycin 1% twice daily for 12 weeks combined with benzoyl peroxide wash; for moderate disease (Hurley Stage II), use clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks; for severe disease (Hurley Stage III) or refractory cases, initiate adalimumab with loading doses of 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting week 4. 1

Disease Severity Assessment

• Determine Hurley stage first to guide treatment selection: Stage I (isolated nodules/abscesses without sinus tracts), Stage II (recurrent abscesses with sinus tracts and scarring in limited areas), Stage III (diffuse involvement with interconnected sinus tracts). 1
• Examine all intertriginous areas (axillae, groin, inframammary, perianal) to assess total disease burden. 1
• Document baseline inflammatory lesion count and pain using Visual Analog Scale. 1

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I)

• First-line: Topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks. 1, 2
• Critical: Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk, as topical clindamycin monotherapy significantly increases antibiotic resistance. 1, 2
• Topical clindamycin reduces superficial pustules but has no effect on deep inflammatory nodules or abscesses—if these are present, escalate to systemic therapy immediately. 2
• Adjunctive: Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) for acutely inflamed nodules provides rapid symptom relief within 1 day with significant reduction in erythema, edema, suppuration, and pain. 1, 2
• Reassess at 12 weeks; if inadequate response, escalate to systemic antibiotics. 1

Moderate Disease (Hurley Stage II)

• First-line: Clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg daily for 10-12 weeks. 1, 3, 4
• This combination achieves response rates of 71-93% and is far superior to tetracycline monotherapy for abscesses and inflammatory nodules. 1, 4
• Alternative if combination unavailable: Doxycycline 100 mg once or twice daily OR lymecycline 408 mg once or twice daily for 12-16 weeks, though these are less effective for acute abscesses. 1, 3
• Do not use doxycycline as first-line for Hurley Stage II with deep inflammatory lesions or abscesses—it has minimal effect on these lesions. 1
• Consider treatment break after 10-12 weeks to assess need for ongoing therapy and limit antimicrobial resistance. 1, 3

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

• First-line biologic: Adalimumab with loading schedule of 160 mg at week 0 (single dose or split over two consecutive days), 80 mg at week 2, then 40 mg weekly starting week 4. 1, 5
• Adalimumab is FDA-approved for moderate to severe HS in patients 12 years and older. 1, 5
• Assess response at 16 weeks using HiSCR (Hidradenitis Suppurativa Clinical Response)—if no clinical response, consider alternative biologics. 1
• Second-line biologic: Infliximab 5 mg/kg at weeks 0,2,6, then every 2 months for patients who fail adalimumab. 1
• Alternative systemic options for adalimumab failures: Acitretin 0.3-0.5 mg/kg/day, dapsone 50-200 mg daily (titrate up), or secukinumab. 1
• Ertapenem 1g IV daily for 6 weeks can be used as rescue therapy or during surgical planning for severe disease requiring IV antibiotics. 1

Surgical Interventions

• Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring—non-surgical methods rarely result in lasting cure for advanced disease. 1
• Deroofing for recurrent nodules and tunnels in localized areas. 1
• Radical surgical excision for extensive disease with sinus tracts and scarring, with wound closure options including secondary intention healing, skin grafts, or flaps. 1
• The width of excision influences therapeutic outcome—wider margins reduce recurrence. 1

Pediatric Dosing

Adolescents 12 Years and Older with HS

• Weight 30-60 kg: Day 1: 80 mg, then 40 mg every other week starting Day 8. 1, 5
• Weight ≥60 kg: Day 1: 160 mg (split over two days if needed), Day 15: 80 mg, then 40 mg weekly OR 80 mg every other week starting Day 29. 1, 5

Children 6 Years and Older (for Crohn's Disease dosing, applicable if HS treatment needed)

• Weight 17-40 kg: Day 1: 80 mg, Day 15: 40 mg, then 20 mg every other week. 1
• Weight ≥40 kg: Day 1: 160 mg, Day 15: 80 mg, then 40 mg every other week. 1

Treatment Escalation Pathway

• If no response after 12 weeks of clindamycin/rifampicin: Consider triple therapy (moxifloxacin + metronidazole + rifampin) or escalate to biologics. 1, 3
• Do not continue doxycycline beyond 4 months without reassessment—prolonged use increases antimicrobial resistance without proven additional benefit. 1
• For dual biologic therapy in treatment-refractory cases: Secukinumab in combination with infliximab targets different inflammatory pathways, with response rates of 64.5-71.4% in adalimumab-failure patients. 1

Essential Adjunctive Measures

• Smoking cessation referral—tobacco use is associated with worse outcomes. 1
• Weight management referral if BMI elevated—obesity worsens disease. 1
• Pain management with NSAIDs for symptomatic relief. 1
• Appropriate wound dressings for draining lesions. 1
• Screen for depression/anxiety—quality of life is significantly impaired. 1, 6
• Screen for cardiovascular risk factors (blood pressure, lipids, HbA1c)—patients with HS and diabetes have increased cardiovascular mortality. 1, 3

Critical Pitfalls to Avoid

• Never use topical clindamycin without benzoyl peroxide or chlorhexidine—this dramatically increases S. aureus resistance. 1, 2
• Never use doxycycline monotherapy for Hurley Stage II with abscesses—it is ineffective for deep lesions. 1
• Never continue long-term antibiotics without treatment breaks—balance benefit against resistance risk. 1, 3
• Never use cryotherapy or microwave ablation during acute phase—these are contraindicated. 1
• Ensure rifampicin dose is 300-600 mg daily, not lower—inadequate dosing reduces efficacy. 3

Monitoring and Follow-up

• Reassess at 12 weeks using pain VAS score, inflammatory lesion count, HiSCR, and quality of life measures (DLQI). 1
• For adalimumab, if no clinical response by 16 weeks, discontinue and consider alternatives. 1
• Monitor all patients for active tuberculosis during biologic treatment, even if initial latent TB test is negative. 5