What are the treatment options for severe hidradenitis suppurativa?

Treatment of Severe Hidradenitis Suppurativa Flare

For a severe hidradenitis suppurativa flare, immediately initiate combination oral clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks, and consider urgent referral to dermatology for potential biologic therapy (adalimumab) or surgical evaluation if Hurley Stage III disease is present. 1, 2

Immediate Assessment and Acute Management

Disease Severity Documentation

• Record Hurley stage for the worst-affected region to guide treatment intensity 1
  • Hurley Stage III (severe): diffuse involvement with multiple interconnected sinus tracts and scarring across entire anatomical region 1
• Measure baseline pain using Visual Analog Scale (VAS) and document inflammatory lesion count 1, 2
• Assess quality of life using Dermatology Life Quality Index (DLQI) and number of flares in the last month 1

Acute Symptom Control

• Provide NSAIDs for pain management during the acute flare 1, 2
• Apply appropriate wound dressings for pus-producing lesions 1
• Consider intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) for acutely inflamed nodules, which provides rapid symptom relief within 1 day with significant reduction in erythema, edema, suppuration, and pain 2

First-Line Systemic Antibiotic Therapy

Combination Clindamycin-Rifampicin Regimen

This is the preferred first-line treatment for severe HS flares 1, 2, 3:

• Clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg daily (or 300 mg twice daily) for 10-12 weeks 1, 2
• This combination achieves response rates of 71-93% in systematic reviews, far superior to monotherapy 2
• The Sartorius score improves dramatically (median reduction from 29 to 14.5, p<0.001) 4
• Rifampicin is critical because it provides antibacterial effects, disrupts bacterial biofilms, has anti-inflammatory properties, and reduces clindamycin resistance 5

Evidence Supporting This Approach

The British Association of Dermatologists guidelines explicitly recommend this combination as second-line therapy after tetracyclines fail, but for Hurley Stage III (severe) disease, consider immediate clindamycin-rifampicin therapy rather than starting with tetracyclines 1. A retrospective study of 116 patients demonstrated dramatic improvement with this regimen, with only 6.9% discontinuing due to side effects 4.

Treatment Duration and Monitoring

• Assess response at 12 weeks using pain VAS, quality of life (DLQI), lesion count, and number of flares 1
• Consider treatment breaks after the 10-12 week course to assess need for ongoing therapy and limit antimicrobial resistance risk 1, 2
• Treatment can be repeated intermittently if the patient responds but relapses 2

Biologic Therapy for Severe/Refractory Disease

Adalimumab (First-Line Biologic)

If antibiotics fail or for Hurley Stage III disease unresponsive to conventional therapy, adalimumab is the only FDA-approved biologic for HS 1, 6:

• Dosing schedule: 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, 2, 6
• FDA-approved for patients 12 years and older with moderate to severe HS 2, 6
• HiSCR response rates: 42% (PIONEER 1) and 59% (PIONEER 2) at week 12 versus 26-28% for placebo 7
• Number needed to treat (NNT) = 4 with favorable benefit-risk ratio 7

Important Caveats About Adalimumab

• 40% of initial non-responders at week 12 may achieve response by week 36 with continued treatment 7
• Almost half of week 12 responders lose response by week 36 despite continued weekly dosing 7
• If no clinical response by 16 weeks, consider alternative treatments 2

Second-Line Biologic Options

If adalimumab fails 1, 2:

• Infliximab 5 mg/kg at weeks 0,2,6, then every 8 weeks 1, 2
• Secukinumab (IL-17 inhibitor) shows 64.5-71.4% response rates in adalimumab-failure patients at 16-52 weeks 2
• Dual biologic therapy (secukinumab + infliximab) is supported for treatment-refractory disease targeting different inflammatory pathways 2

Alternative Systemic Therapies

Oral Retinoids

Consider acitretin 0.3-0.5 mg/kg/day in males and non-fertile females unresponsive to antibiotics 1, 2:

• This is a weak recommendation (↑) based on limited evidence 1
• Requires strict contraception in females of childbearing potential

Dapsone

Consider dapsone (starting at 50 mg daily, titrating up to 200 mg daily) as an alternative for patients unresponsive to adalimumab 1, 2:

• This is a weak recommendation (↑) based on limited evidence 1
• Requires G6PD screening before initiation

Rescue Therapy for Severe Flares

Ertapenem 1g IV daily for 6 weeks can be considered as rescue therapy or during surgical planning for severe disease requiring IV antibiotics 2

Surgical Intervention

Indications for Surgery

Refer to HS surgical multidisciplinary team for 1, 2:

• Hurley Stage III disease with extensive sinus tracts and scarring 1
• Lack of response to medical therapy including biologics 1
• Recurrent nodules and tunnels amenable to deroofing 2

Surgical Options

• Radical surgical excision for extensive disease with healing by secondary intention, TDAP flap, or other reconstructive methods 1, 2
• Deroofing for recurrent nodules and tunnels 2
• Surgery is often necessary for lasting cure, especially in advanced disease 2

Essential Adjunctive Measures

Lifestyle Modifications

• Refer to smoking cessation services if relevant, as tobacco use is associated with worse outcomes and predicts poor antibiotic response 1, 2, 3
• Refer to weight management services if relevant, as high BMI predicts poor response to antibiotics 1, 2, 3

Comorbidity Screening

Screen all patients for 1, 2:

• Depression and anxiety (common in HS patients) 1
• Cardiovascular risk factors: measure blood pressure, lipids, HbA1c 1, 2
• Inflammatory bowel disease if persistent GI symptoms reported 1
• Metabolic syndrome components 8

Topical Adjuncts

Apply topical clindamycin 1% solution twice daily to all affected areas, though this is primarily for mild disease 1, 2:

• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 2

Critical Pitfalls to Avoid

Do Not Use Tetracyclines as First-Line for Severe Flares

Doxycycline or lymecycline monotherapy has minimal effect on deep inflammatory lesions, abscesses, and sinus tracts characteristic of severe HS 2. While the British Association of Dermatologists recommends tetracyclines as first-line for moderate disease 1, for Hurley Stage III (severe) disease, consider immediate clindamycin-rifampicin therapy 1.

Do Not Continue Ineffective Antibiotics Beyond 12 Weeks

If no clinical response after 12 weeks of antibiotics, escalate to biologics or refer for surgery 1, 2. Prolonged antibiotic use without benefit increases antimicrobial resistance risk 1.

Do Not Ignore Predictors of Poor Response

High BMI and smoking pack-years correlate with poor antibiotic response 3. Address these factors aggressively while initiating medical therapy.

Beware of Adalimumab's Limitations

Non-surgical methods rarely result in lasting cure for advanced disease 2. Even responders to adalimumab may lose response over time 7. Have a clear plan for surgical referral if medical therapy fails.

Monitor for Serious Adverse Events with Biologics

TNF blockers carry risks of serious infections, malignancy (including hepatosplenic T-cell lymphoma in young males on concomitant azathioprine/6-MP), and reactivation of latent tuberculosis 6. Screen for TB before initiating adalimumab and monitor closely.