What are the treatment options for hydradenitis suppurativa?

Treatment Options for Hidradenitis Suppurativa

Treatment selection for hidradenitis suppurativa must be based on Hurley staging, with topical clindamycin for mild disease (Stage I), combination oral clindamycin plus rifampicin for moderate disease (Stage II), and adalimumab for severe or refractory disease (Stage III), combined with surgical intervention when fibrotic lesions or sinus tracts are present. 1, 2

Disease Severity Assessment

Before initiating treatment, determine Hurley stage by examining all intertriginous areas (axillae, groin, inframammary, perianal) to assess for isolated nodules (Stage I), recurrent nodules with sinus tracts (Stage II), or diffuse involvement with multiple interconnected tracts and scarring (Stage III). 1, 2 Document baseline pain using Visual Analog Scale and count inflammatory lesions (abscesses, nodules, draining tunnels). 2

Mild Disease (Hurley Stage I)

For localized disease with isolated nodules and no sinus tracts, initiate topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks. 1, 2, 3

• Combine topical clindamycin with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk, which is a significant concern with clindamycin monotherapy. 1, 2
• For acutely inflamed nodules causing severe pain, inject intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) to achieve rapid symptom relief within 24 hours. 1, 2
• Resorcinol 15% cream applied to affected areas can reduce pain and abscess duration, though irritant dermatitis occurs commonly and limits tolerability. 1, 2

If topical therapy fails after 12 weeks, escalate to oral tetracyclines: doxycycline 100 mg once or twice daily for 12-16 weeks, or lymecycline 408 mg once or twice daily for 12 weeks. 1, 2 However, tetracycline monotherapy shows only modest efficacy (30% abscess reduction) and is not recommended as first-line for disease with deep inflammatory lesions. 2

Moderate Disease (Hurley Stage II)

For recurrent nodules with abscesses and sinus tracts, prescribe clindamycin 300 mg orally twice daily plus rifampicin 300-600 mg orally once or twice daily for 10-12 weeks as first-line systemic therapy. 1, 2, 3

This combination demonstrates superior efficacy with response rates of 71-93% in systematic reviews, far exceeding tetracycline monotherapy. 2 The regimen can be repeated intermittently for maintenance or used as adjuvant therapy with biologics in severe disease. 1, 2

Alternative second-line antibiotic regimens include:

• Moxifloxacin, metronidazole, and rifampin in combination (triple therapy) for patients failing clindamycin-rifampicin. 1
• Intravenous ertapenem 1g daily for 6 weeks as rescue therapy or bridge to surgery in severe disease requiring hospitalization. 1, 2

Critical pitfall: Take treatment breaks after 10-12 week antibiotic courses to assess ongoing need and limit antimicrobial resistance development. 2 Recurrence after cessation is frequent, requiring transition to maintenance therapy or biologics. 1

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

For extensive disease with multiple interconnected sinus tracts, scarring, or failure of antibiotics, initiate adalimumab with loading dose of 160 mg at week 0 (given as four 40 mg injections in one day or split over two consecutive days), followed by 80 mg at week 2, then 40 mg weekly starting at week 4. 1, 2, 3, 4

Adalimumab is FDA-approved for moderate-to-severe hidradenitis suppurativa in adults and adolescents 12 years and older. 4 For adolescents weighing 30-60 kg, use 80 mg at day 1, then 40 mg every other week; for those ≥60 kg, use adult dosing. 4

If adalimumab fails after 16 weeks (assessed by HiSCR: ≥50% reduction in inflammatory lesion count), consider:

• Infliximab 5 mg/kg intravenously at weeks 0,2,6, then every 8 weeks as second-line biologic. 1, 2
• Secukinumab (IL-17 inhibitor) for adalimumab-failure patients, with response rates of 64.5-71.4% at 16-52 weeks. 2
• Bimekizumab (dual IL-17A/F inhibitor) as emerging option. 5

Alternative immunosuppressive options with weaker evidence:

• Acitretin 0.3-0.5 mg/kg/day for patients unresponsive to adalimumab, though teratogenicity limits use in reproductive-age females. 1, 6
• Dapsone 50-200 mg daily for minority of patients with Hurley I-II disease as maintenance therapy. 1, 2

Surgical Interventions

Surgery is essential for achieving lasting cure in advanced disease with fibrotic sinus tracts and scarring, as these structural changes do not respond to medical therapy alone. 1, 7

Surgical options based on lesion characteristics:

• Deroofing: For recurrent nodules and individual sinus tracts without extensive scarring—unroof the tract to allow drainage and healing by secondary intention. 1, 3
• Wide local excision: For extensive chronic lesions with multiple interconnected tracts and scarring—excise all affected tissue with 1-2 cm margins down to subcutaneous fat. 1 Non-recurrence rates reach 81.25% with adequate excision margins. 8
• Incision and drainage: Only for acute abscesses to relieve pain temporarily; this does NOT treat underlying disease and recurrence is universal. 1

Wound closure options include secondary intention healing (preferred for smaller defects), delayed primary closure, skin grafts, or flaps (TDAP flap for larger defects). 1, 2 Continue medical therapy perioperatively to minimize recurrence risk. 1

CO2 laser excision is recommended for Hurley Stage II-III disease with fibrotic sinus tracts as alternative to scalpel excision. 1 Nd:YAG laser for follicular destruction shows efficacy in Stage II-III disease based on RCT data. 1

Hormonal Therapies

For appropriate female patients, consider hormonal agents as monotherapy for mild-to-moderate disease or combined with other treatments for severe disease: 1

• Combined oral contraceptives containing estrogen
• Spironolactone
• Cyproterone acetate
• Metformin (particularly if metabolic syndrome present)
• Finasteride

Avoid progestogen-only contraceptives, as anecdotal data suggest they may worsen hidradenitis suppurativa. 1

Adjunctive Therapies (Essential for All Patients)

Regardless of medical or surgical treatment chosen, address these modifiable factors:

Lifestyle modifications:

• Smoking cessation referral (tobacco use associated with worse outcomes). 2, 8
• Weight loss for patients with obesity (BMI >30), as obesity increases disease severity. 2, 3, 8

Comorbidity screening and management:

• Screen for depression and anxiety, which are highly prevalent. 2, 8
• Measure blood pressure, lipids, and HbA1c to assess cardiovascular risk factors. 2, 8
• Evaluate for inflammatory bowel disease, metabolic syndrome, and inflammatory arthritis. 2, 5

Symptomatic management:

• NSAIDs for pain control. 2, 8
• Appropriate wound dressings for draining lesions based on exudate volume, location, and patient preference. 1, 2
• Antiseptic washes (chlorhexidine, zinc pyrithione) for all affected areas, though contact dermatitis risk exists. 1

Treatment Monitoring and Escalation

Reassess all patients at 12 weeks using: 2, 8

• Pain VAS score
• Inflammatory lesion count (abscesses, nodules, draining tunnels)
• Dermatology Life Quality Index (DLQI)
• HiSCR for patients on biologic therapy (≥50% reduction in inflammatory lesions)

If inadequate response after 12 weeks, escalate treatment according to the algorithm above—do not continue ineffective therapy beyond this timepoint. 2 For patients on adalimumab, if no clinical response by 16 weeks, switch to alternative biologic or consider surgical intervention. 2, 4

Critical Pitfalls to Avoid

• Never use incision and drainage as definitive treatment—it only provides temporary pain relief and does not address underlying disease. 1
• Do not use doxycycline monotherapy as first-line for Hurley Stage II disease with abscesses or deep inflammatory nodules—it has minimal effect on these lesions. 2
• Avoid long-term continuous antibiotic use without treatment breaks—this increases antimicrobial resistance without proven additional benefit. 1, 2
• Do not delay surgical referral in patients with established fibrotic sinus tracts and scarring—these structural changes will not respond to medical therapy alone. 1, 7
• Cryotherapy and microwave ablation are not recommended for treating acute lesions. 2