What are the treatment options for managing hidradenitis suppurativa?

Management of Hidradenitis Suppurativa

Initial Assessment and Staging

Begin treatment based on Hurley staging, which determines disease severity and guides therapeutic selection. 1

• Hurley Stage I: Isolated nodules and abscesses without sinus tracts or scarring 2
• 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 the entire area 1

Document baseline pain using Visual Analog Scale (VAS), inflammatory lesion count, and quality of life using Dermatology Life Quality Index (DLQI) at initial presentation. 1, 3

Screen all patients for comorbidities including depression, anxiety, diabetes, hypertension, hyperlipidemia, central obesity, and inflammatory bowel disease (if persistent GI symptoms present). 1, 3

Treatment Algorithm by Disease Severity

Hurley Stage I (Mild Disease)

Offer topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks as first-line therapy. 1, 2

• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 1, 3
• For acutely inflamed nodules, inject intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) for rapid symptom relief within 1 day 1, 3
• Resorcinol 15% cream may be used but frequently causes contact dermatitis 1

If topical therapy fails after 12 weeks, escalate to oral tetracycline 500 mg twice daily or doxycycline 100 mg once or twice daily for 12-16 weeks. 1, 3

Hurley Stage II (Moderate Disease)

Offer clindamycin 300 mg orally twice daily plus rifampicin 300-600 mg orally once or twice daily for 10-12 weeks as first-line therapy. 1, 2

• This combination achieves response rates of 71-93% and is superior to tetracycline monotherapy 1, 2
• Treatment can be repeated intermittently as monotherapy or as adjuvant therapy in severe disease 1
• Take a treatment break after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 3

If clindamycin-rifampicin fails after 10-12 weeks, offer triple therapy with moxifloxacin, metronidazole, and rifampin as second-line treatment. 1

If second-line antibiotics fail, offer adalimumab 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, 2, 4

Hurley Stage III (Severe Disease)

Offer adalimumab as first-line biologic therapy with the dosing schedule: 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting week 4. 1, 2, 4

• Adalimumab is the only FDA-approved biologic for moderate-to-severe HS 4
• Discontinue if no clinical response by 16 weeks (Day 113) 2, 4
• Continue therapy as long as HS lesions are present if improvement occurs 1

If adalimumab fails, offer infliximab 5 mg/kg at weeks 0,2,6, and every 2 months thereafter. 1, 2

• Higher doses and more frequent intervals may be needed for severe refractory cases 2
• Secukinumab may be added for dual biologic therapy in treatment-refractory disease, with response rates of 64.5-71.4% in adalimumab-failure patients 2

Consider IV ertapenem 1g daily for 6 weeks as rescue therapy or bridge to surgery in severe disease requiring IV antibiotics. 1

Surgical Management

Offer surgical intervention for all patients with sinus tracts, scarring, or recurrent nodules unresponsive to medical therapy. 1

• Deroofing: For recurrent nodules and tunnels without extensive scarring 1, 2
• Wide local excision: For extensive chronic lesions with sinus tracts and scarring, achieving non-recurrence rates of 81.25% 1, 2
• CO2 laser excision: For Hurley stage II or III disease with fibrotic sinus tracts 1
• Wound healing options include secondary intention, primary closure, delayed primary closure, flaps, grafts, or skin substitutes 1
• Continue medical therapy perioperatively as it poses minimal risk of increased postoperative complications 1

Do not offer incision and drainage except for acute abscesses to relieve pain, as it does not prevent recurrence. 1

Adjunctive and Alternative Therapies

Hormonal Therapy (for appropriate female patients)

Consider combined oral contraceptives, spironolactone, or cyproterone acetate as monotherapy for mild-to-moderate disease or in combination with other agents for severe disease. 1

• Avoid progestogen-only contraceptives as they may worsen HS 1
• Metformin and finasteride may also be considered 1

Laser and Light Therapy

Offer Nd:YAG laser for Hurley stage II or III disease based on RCT data. 1

• Other wavelengths for follicular destruction have lower-quality evidence 1
• External beam radiation and photodynamic therapy have limited roles 1

Alternative Systemic Options

Consider acitretin 0.3-0.5 mg/kg/day or dapsone 50-200 mg daily as alternatives for patients unresponsive to adalimumab. 1, 3

• Acitretin requires contraception in females of reproductive age due to teratogenicity 5
• Dapsone may be effective for a minority of patients with Hurley stage I or II disease 1

Essential Adjuvant Measures (All Patients)

Provide the following to all patients regardless of disease severity: 1

• Patient information leaflet 1
• Pain management with NSAIDs or other analgesics as needed 1, 3
• Appropriate wound dressings for draining lesions based on drainage amount, location, and patient preference 1
• Referral to smoking cessation services (smoking worsens outcomes) 1, 2, 3
• Referral to weight management services if BMI elevated (obesity increases severity) 1, 2, 3

Monitoring and Reassessment

Reassess all patients at 12 weeks using: 1, 3

• Pain VAS score 1, 3
• Inflammatory lesion count 1, 3
• DLQI 1, 3
• Hidradenitis Suppurativa Clinical Response (HiSCR) for patients on biologic therapy 2, 3

Escalate therapy if inadequate response after 12 weeks. 2, 3

Special Populations

For adolescents 12 years and older with moderate-to-severe HS: 2, 4

• Weight 30-60 kg: 80 mg on Day 1, then 40 mg every other week starting Day 8 4
• Weight ≥60 kg: 160 mg on Day 1,80 mg on Day 15, then 40 mg weekly or 80 mg every other week starting Day 29 4

For children 6 years and older with Crohn's disease-like HS requiring systemic therapy, doxycycline is recommended. 2

Critical Pitfalls to Avoid

• Do not use doxycycline monotherapy as first-line for Hurley stage II disease with deep inflammatory lesions or abscesses, as it has minimal effect on these lesions 2
• Do not continue doxycycline beyond 4 months without reassessment, as prolonged use increases antimicrobial resistance without proven additional benefit 2
• Do not offer cryotherapy or microwave ablation for acute lesions, as guidelines recommend against these 3
• Do not delay referral to dermatology for Hurley stage III disease, as immediate specialist referral is indicated 1