What is the management approach for hidradenitis?

Management of Hidradenitis Suppurativa

Manage hidradenitis suppurativa using a severity-based algorithmic approach: topical clindamycin for mild disease (Hurley Stage I), clindamycin plus rifampicin for moderate disease (Hurley Stage II), and adalimumab for severe or refractory disease (Hurley Stage III), with surgical excision reserved for fibrotic lesions and sinus tracts that do not respond to medical therapy. 1, 2

Initial Assessment and Staging

• Document Hurley stage at baseline for the worst-affected anatomical region to guide treatment selection 3

  • 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 abscesses across an entire anatomical area 3

• Examine all intertriginous areas (axillae, groin, inframammary, perianal, buttocks) to determine total disease burden 1

• Measure baseline pain using Visual Analog Scale (VAS) and document inflammatory lesion count 1

• Screen for critical comorbidities including depression, anxiety, diabetes, hypertension, hyperlipidemia, inflammatory bowel disease (if persistent GI symptoms present) 3, 1

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I)

First-line therapy:

• Topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks 1, 2, 4
• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 1
• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) for acutely inflamed nodules provides rapid symptom relief within 1 day 1

If inadequate response after 12 weeks:

• Escalate to oral tetracycline 500 mg twice daily OR doxycycline 100 mg once or twice daily for 12-16 weeks 1, 4
• Alternative: Lymecycline 408 mg once or twice daily for 12 weeks 3, 1

Moderate Disease (Hurley Stage II)

First-line therapy:

• Clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg daily for 10-12 weeks 1, 2, 4
• This combination achieves 71-93% response rates, far superior to tetracycline monotherapy 1
• Do NOT use doxycycline monotherapy as first-line for Hurley Stage II with abscesses or deep inflammatory nodules—it has minimal effect on these lesions 1

Treatment breaks:

• Consider a treatment break after completing the 10-12 week course to assess need for ongoing therapy and limit antimicrobial resistance 1

If inadequate response after 12 weeks:

• Escalate to adalimumab (see severe disease protocol below) 1, 2

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

First-line biologic therapy:

• Adalimumab dosing for 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 week 4 1, 2, 5
• Adalimumab dosing for adolescents 12+ years weighing 30-60 kg: 80 mg on Day 1, then 40 mg every other week starting Day 8 5
• Adalimumab dosing for adolescents 12+ years weighing ≥60 kg: Use adult dosing regimen 5

Assess treatment response at 16 weeks:

• Use HiSCR (Hidradenitis Suppurativa Clinical Response): ≥50% reduction in inflammatory lesion count with no increase in abscesses or draining fistulas 1, 2
• Discontinue adalimumab if no clinical response by 16 weeks and consider alternative treatments 1

Second-line biologic therapy (if adalimumab fails):

• Infliximab 5 mg/kg at weeks 0,2,6, then every 2 months 1, 2
• Higher doses and more frequent intervals may be needed for severe refractory cases 1

Alternative systemic options (if biologics contraindicated or failed):

• Acitretin 0.3-0.5 mg/kg/day 1
• Dapsone 50 mg daily, titrating up to 200 mg daily (check G6PD before initiating) 1
• Ertapenem 1g IV daily for 6 weeks as rescue therapy or during surgical planning 1

Surgical Management

Indications for surgery:

• Extensive disease with sinus tracts and scarring (Hurley Stage III) 1, 2
• Recurrent nodules and tunnels despite medical therapy 4
• Fibrotic lesions are NOT susceptible to medical treatment and require surgical intervention 6, 7

Surgical options:

• Deroofing for recurrent nodules and tunnels 1, 4
• Radical surgical excision for extensive disease with wide margins 1, 2, 7
• Wound closure options: secondary intention healing (preferred for large defects), TDAP flap, skin grafts, or other reconstructive methods 1, 7
• Avoid split-thickness skin grafts in the anal canal—they contract and cause anal stenosis 7

Critical surgical pitfall:

• Do NOT perform simple incision and drainage—this provides only temporary relief and does not address underlying pathology 6, 7
• Wide excision offers the most definitive therapy with non-recurrence rates of 81.25%, though with higher morbidity 2, 7

Adjunctive Therapies (Essential for All Patients)

• Refer to smoking cessation services—tobacco use is associated with worse outcomes 3, 1, 2
• Refer to weight management services if BMI elevated—obesity increases disease severity 3, 1, 4
• Pain management with NSAIDs for symptomatic relief 1, 2
• Appropriate wound dressings for draining lesions 3, 1
• Screen and treat depression/anxiety—HS has profound impact on quality of life 3, 1, 2
• Measure blood pressure, lipids, and HbA1c to screen for cardiovascular risk factors 3, 1, 2

Monitoring and Reassessment

• Reassess at 12 weeks using pain VAS score, inflammatory lesion count, and DLQI (Dermatology Life Quality Index) 1, 2
• For patients on adalimumab, use HiSCR at 16 weeks to determine treatment continuation 1, 2
• Monitor for long-standing moderate-to-severe HS complications: fistulating gastrointestinal disease, inflammatory arthritis, genital lymphedema 3

Therapies with Insufficient Evidence (Do Not Recommend)

The British Association of Dermatologists states insufficient evidence exists for: alitretinoin, anakinra, apremilast, azathioprine, ciclosporin, colchicine, methotrexate, oral prednisolone, laser therapies, photodynamic therapy, radiotherapy, secukinumab (as monotherapy), ustekinumab, and numerous others 1

Strong recommendation AGAINST:

• Cryotherapy and microwave ablation for treating lesions during the acute phase 1

Critical Pitfalls to Avoid

• Do not use doxycycline as first-line for Hurley Stage II disease—it lacks efficacy for abscesses and deep inflammatory nodules 1
• Do not continue antibiotics beyond 4 months without reassessment—this increases antimicrobial resistance without proven benefit 1
• Do not delay referral to dermatology for Hurley Stage III disease—immediate specialist referral is indicated 3
• Do not treat HS as a simple boil or abscess with incision and drainage alone—this is inappropriate and ineffective 6
• Do not expect medical therapy alone to cure advanced disease with fibrosis—surgery is necessary for lasting cure 2, 6, 7