What are the treatment options for hidradenitis suppurativa?

Hidradenitis Suppurativa Treatment

For mild disease (Hurley Stage I), start with topical clindamycin 1% twice daily for 12 weeks; for moderate disease (Hurley Stage II), use clindamycin 300 mg plus rifampicin 600 mg orally twice daily for 10-12 weeks; and for severe or refractory disease (Hurley Stage III), initiate adalimumab with loading doses of 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting week 4. 1, 2, 3

Disease Severity Assessment

Before initiating treatment, determine disease severity using the Hurley staging system: 1, 2, 3

• Hurley Stage I (Mild): Isolated nodules and abscesses without sinus tracts or scarring 1
• 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 anatomical area 1

Document baseline pain using Visual Analog Scale (VAS) and count inflammatory lesions (nodules, abscesses, draining tunnels) to track treatment response. 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, 3

Critical adjunct: Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk, as topical clindamycin monotherapy increases resistance rates. 1, 2

For inflamed nodules: Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) provides rapid symptom relief within 1 day, with significant reduction in erythema, edema, suppuration, and pain. 1

Alternative topical option: Resorcinol 15% cream reduces pain and abscess duration, though irritant dermatitis is a common side effect. 1

If inadequate response after 12 weeks: Escalate to oral tetracyclines (doxycycline 100 mg once or twice daily or lymecycline 408 mg once or twice daily) for 12-16 weeks. 1 However, tetracycline monotherapy showed only 30% reduction in abscesses in RCTs with no significant improvement in patient-reported outcomes. 1

Moderate Disease (Hurley Stage II)

First-line therapy: Clindamycin 300 mg orally twice daily plus rifampicin 600 mg orally once or twice daily for 10-12 weeks. 1, 2, 3 This combination demonstrates response rates of 71-93% in systematic reviews, far superior to tetracycline monotherapy. 1

Do not use doxycycline as first-line for Hurley Stage II with deep inflammatory lesions or abscesses, as it has minimal effect on these lesions. 1

Treatment duration: The clindamycin-rifampicin regimen typically lasts 8-12 weeks and can be repeated intermittently as monotherapy in mild-to-moderate disease or as adjuvant therapy in severe disease. 1

Important caveat: Recurrence rates are high after discontinuation of clindamycin plus rifampicin combination therapy. 4 Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance. 1

If inadequate response after 12 weeks: Escalate to adalimumab or consider surgical intervention. 1

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

First-line biologic therapy: Adalimumab with the following FDA-approved dosing schedule: 1, 2, 3, 5

• 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, 5
• Adolescents ≥60 kg (≥132 lbs): Same as adult dosing 5
• Adolescents 30-60 kg (66-132 lbs): 80 mg at day 1, then 40 mg every other week starting day 8 5

Treatment assessment: Evaluate response at 12-16 weeks using Hidradenitis Suppurativa Clinical Response (HiSCR), which measures ≥50% reduction in inflammatory lesion count with no increase in abscesses or draining fistulas. 1, 2, 3 If no clinical response after 16 weeks, consider alternative treatments. 1, 3

Second-line biologic: Infliximab 5 mg/kg at weeks 0,2,6, and every 2 months thereafter for patients who fail adalimumab. 1 Higher doses and more frequent intervals are supported for severe refractory cases. 1

Alternative systemic options for adalimumab failures: 1

• Acitretin 0.3-0.5 mg/kg/day (long-term treatment feasible, but teratogenicity must be considered in females of reproductive age) 4
• Dapsone 50 mg daily, titrating up to 200 mg daily 1
• Ertapenem 1g daily IV for 6 weeks as rescue therapy or during surgical planning 1

Emerging biologics: 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, 6, 7

Surgical Interventions

Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring. 1, 2, 3 Non-surgical methods rarely result in lasting cure for advanced disease. 1

Surgical options: 1, 2

• Deroofing: For recurrent nodules and tunnels 1
• Radical surgical excision: For extensive disease with sinus tracts and scarring, with non-recurrence rates of 81.25% after wide excision 2
• Wound closure options: Secondary intention healing, skin grafts, TDAP flap, or other reconstructive methods 1

The width of excision influences therapeutic outcome—wider excisions have better outcomes. 1

Pediatric Populations

Adolescents ≥12 years with moderate to severe disease: Adalimumab is FDA-approved with weight-based dosing as outlined above. 1, 5

Children ≥8 years requiring systemic antibiotics: Oral doxycycline is recommended. 1

Children 6-11 years with Crohn's disease-like HS: Weight-based adalimumab dosing available per FDA label. 5

Essential Adjunctive Measures (Apply to All Patients)

These interventions improve outcomes and must be addressed regardless of pharmacologic treatment: 1, 2, 3

• Smoking cessation referral: Tobacco use is associated with worse outcomes 1, 3
• Weight management referral if BMI elevated: Obesity worsens disease 1, 3
• Pain management: NSAIDs for symptomatic relief 1, 3
• Appropriate wound dressings for draining lesions 1, 3
• Screen for depression/anxiety: HS has profound negative impact on quality of life 1, 6
• Screen for cardiovascular risk factors: Measure blood pressure, lipids, HbA1c 1
• Screen for comorbidities: Inflammatory bowel disease, inflammatory arthritis, metabolic syndrome 1, 6

Monitoring and Reassessment

At 12 weeks, reassess all patients using: 1, 2, 3

• Pain VAS score
• Inflammatory lesion count (nodules, abscesses, draining tunnels)
• Dermatology Life Quality Index (DLQI)
• HiSCR for patients on biologic therapy

Treatment breaks: After antibiotic courses, consider treatment breaks to assess need for ongoing therapy and limit antimicrobial resistance. 1

Treatments with Insufficient Evidence

The following therapies lack sufficient evidence and are not recommended: alitretinoin, anakinra, apremilast, atorvastatin, azathioprine, ciclosporin, colchicine, cyproterone, finasteride, fumaric acid esters, methotrexate, oral prednisolone, oral zinc, phototherapy, ustekinumab, cryotherapy, and microwave ablation. 1

Critical Pitfalls to Avoid

• Do not use doxycycline monotherapy as first-line for Hurley Stage II with abscesses or inflammatory nodules—it has minimal effect on these lesions. 1
• Do not continue doxycycline beyond 4 months without reassessment, as prolonged use increases antimicrobial resistance without proven additional benefit. 1
• Do not use topical clindamycin without benzoyl peroxide or chlorhexidine, as this increases Staphylococcus aureus resistance. 1, 2
• Do not delay biologic therapy in severe disease—early intervention prevents irreversible skin damage with tunnel formation and morbid scarring. 6