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 (clindamycin plus rifampicin) for moderate disease, and adalimumab for severe or refractory cases, with surgery reserved for extensive fibrotic disease. 1, 2, 3

Disease Severity Assessment

Before initiating therapy, determine disease severity using the Hurley staging system 1, 3:

• Hurley Stage I (Mild): Isolated nodules and abscesses without sinus tracts or scarring 3
• Hurley Stage II (Moderate): Recurrent abscesses with sinus tract formation and scarring, separated by normal skin 1
• Hurley Stage III (Severe): 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, document baseline pain using Visual Analog Scale, and count inflammatory lesions 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, 2, 3

• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 1, 3
• Alternative adjunctive cleansers include zinc pyrithione 1
• For acutely inflamed nodules, inject intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion), which provides rapid symptom relief within 1 day with significant reduction in erythema, edema, suppuration, and pain 1

If inadequate response after 12 weeks, escalate to oral tetracycline 500 mg twice daily or doxycycline 100 mg once or twice daily for up to 4 months (12-16 weeks) for more widespread mild disease 1, 2.

Moderate Disease (Hurley Stage II)

First-line therapy is clindamycin 300 mg orally twice daily plus rifampicin 300-600 mg daily (typically 600 mg once daily) for 10-12 weeks. 1, 2, 3

• This combination achieves response rates of 71-93% in systematic reviews, far superior to tetracycline monotherapy 1
• Treatment typically lasts 8-12 weeks and can be repeated intermittently 1
• Consider a treatment break after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1

Common pitfall: Do not use doxycycline monotherapy as first-line for Hurley Stage II with deep inflammatory lesions or abscesses, as it has minimal effect on these lesions 1. Clindamycin-rifampicin is the superior choice for this stage 1.

If no clinical response after 12 weeks, escalate to adalimumab or consider triple antibiotic therapy (moxifloxacin + metronidazole + rifampicin) 1.

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

First-line biologic therapy is adalimumab with the following FDA-approved dosing regimen 1, 2, 3, 4:

• Adults: 160 mg at week 0 (given in one day 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: Use 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 HiSCR (Hidradenitis Suppurativa Clinical Response: ≥50% reduction in inflammatory lesions) 1. If no clinical response after 16 weeks, discontinue adalimumab and consider alternative treatments 1.

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, 2 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 (note: teratogenic, requires contraception)
• Dapsone 50 mg daily titrating up to 200 mg daily (check G6PD before initiating)
• Ertapenem 1g IV daily for 6 weeks as rescue therapy or during surgical planning

Emerging option: Secukinumab (IL-17 inhibitor) shows response rates of 64.5-71.4% in adalimumab-failure patients at 16-52 weeks and can be used in combination with infliximab for treatment-refractory disease 1.

Surgical Interventions

Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring. 1, 3 Non-surgical methods rarely result in lasting cure for advanced disease 1.

Surgical Options by Disease Extent

• Deroofing: For recurrent nodules and tunnels without extensive scarring 1, 2
• Radical surgical excision: For extensive disease with sinus tracts and scarring, with non-recurrence rates of 81.25% after wide excision 1, 3
• Wound closure options: Secondary intention healing, skin grafts, TDAP flap, or other reconstructive methods 1, 3

The width of excision influences therapeutic outcome—wider margins correlate with better outcomes 1.

Adjunctive Therapies and Comorbidity Management

Essential lifestyle modifications 1, 3:

• Smoking cessation referral (tobacco use associated with worse outcomes)
• Weight loss for patients with obesity (obesity increases HS severity)
• Pain management with NSAIDs for symptomatic relief
• Appropriate wound dressings for draining lesions

Mandatory comorbidity screening 1:

• Depression and anxiety screening
• Cardiovascular risk factors: measure blood pressure, lipids, HbA1c
• Screen for inflammatory bowel disease, diabetes, hypertension, hyperlipidemia

Monitoring and Reassessment

Reassess all patients at 12 weeks using 1:

• Pain Visual Analog Scale score
• Inflammatory lesion count
• Dermatology Life Quality Index (DLQI)
• HiSCR for patients on biologic therapy

Treatment escalation criteria: If inadequate response after 12 weeks of current therapy, escalate to next treatment tier 1, 2.

Therapies with Insufficient Evidence

The British Journal of Dermatology states there is insufficient evidence to recommend: alitretinoin, anakinra, apremilast, azathioprine, ciclosporin, colchicine, methotrexate, oral prednisolone, ustekinumab, laser therapies, phototherapy, and numerous other agents 1. Do not use cryotherapy or microwave ablation for acute lesions 1.