What is the recommended treatment for Hidradenitis Suppurativa (HS)?

Treatment for Hidradenitis Suppurativa

Start with oral tetracyclines (doxycycline or lymecycline) for at least 12 weeks as first-line systemic therapy, escalate to clindamycin 300 mg plus rifampicin 300 mg twice daily for 10-12 weeks if unresponsive, and offer adalimumab 40 mg weekly for moderate-to-severe disease that fails conventional antibiotics. 1

Disease Severity Assessment and Initial Management

• Document Hurley stage at baseline for the worst-affected region to guide treatment selection 1

  • Hurley Stage I: Isolated nodules/abscesses without sinus tracts or scarring
  • Hurley Stage II: Recurrent abscesses with sinus tract formation and scarring, separated by normal skin
  • Hurley Stage III: Diffuse involvement with multiple interconnected tracts and abscesses 2

• Immediate dermatology referral is indicated for Hurley Stage III (severe) disease 1

• Screen all patients at baseline for depression, anxiety, cardiovascular risk factors (diabetes, hypertension, hyperlipidemia, central obesity), and inflammatory bowel disease if persistent GI symptoms present 1

Topical and Local Therapies

Mild Disease (Hurley Stage I)

• Topical clindamycin 1% solution/gel twice daily for 12 weeks is first-line therapy 1, 2

  • Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 2
  • Note: Topical clindamycin increases rates of S. aureus resistance in HS patients 1

• Resorcinol 15% cream (keratolytic and antiseptic) applied twice daily for flares and daily between flares reduces pain and abscess duration, though irritant dermatitis is frequent 1, 2

  • Recent evidence shows resorcinol 15% may be superior to clindamycin 1% for mild-to-moderate disease 3

• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) for acute, inflamed nodules provides rapid symptom relief within 1 day, with significant reductions in erythema, edema, suppuration, and pain 1, 2

Systemic Antibiotic Therapy

First-Line: Oral Tetracyclines

• Doxycycline 100 mg once or twice daily OR lymecycline 408 mg once or twice daily for at least 12 weeks 1, 2
  • Can extend up to 4 months (16 weeks) for more widespread mild disease 1, 2
  • Consider treatment breaks after courses to assess need for ongoing therapy and limit antimicrobial resistance 1
  • Critical limitation: Tetracycline monotherapy showed only 30% reduction in abscesses in RCT, with minimal effect on inflammatory nodules characteristic of Hurley Stage II 1, 2

Second-Line: Clindamycin-Rifampicin Combination

• Clindamycin 300 mg twice daily PLUS rifampicin 300 mg twice daily for 10-12 weeks for patients unresponsive to tetracyclines 1, 2
  • This is the superior first-line choice for Hurley Stage II disease with response rates of 71-93% in systematic reviews 2
  • Can be repeated intermittently as monotherapy in mild-to-moderate disease or as adjuvant therapy in severe disease 1, 2
  • Recurrence rate is high after discontinuation 4

Alternative Systemic Options

• Acitretin 0.3-0.5 mg/kg/day in males and non-fertile females unresponsive to antibiotics 1

  • Long-term treatment is feasible, but teratogenicity must be considered 4

• Dapsone (starting 50 mg daily, titrating to 200 mg daily) for patients unresponsive to antibiotics 1, 2

• Ertapenem 1g daily for 6 weeks as rescue therapy or during surgical planning for severe disease requiring IV antibiotics 2

Biologic Therapy

First-Line Biologic: Adalimumab

• Adalimumab 40 mg weekly (NOT every other week) for moderate-to-severe HS unresponsive to conventional systemic therapy 1, 5

  • Adult dosing: 160 mg at Week 0 (single dose or split over two consecutive days), 80 mg at Week 2, then 40 mg weekly starting Week 4 1, 2, 5
  • Adolescents ≥12 years, ≥60 kg: Same as adult dosing 1, 5
  • Adolescents ≥12 years, 30-60 kg: 80 mg at Day 1, then 40 mg every other week starting Day 8 1, 5
  • FDA-approved for ages ≥12 years (strong recommendation), suggested for ages 2-11 years 1, 6, 5
  • Do NOT use adalimumab 40 mg every other week for moderate-to-severe HS—this dosing is explicitly not recommended 1

• Measure treatment response using Hidradenitis Suppurativa Clinical Response (HiSCR), inflammatory lesion count, pain VAS, and quality of life measures (DLQI) at 12-16 weeks 1, 2

  • If no clinical response by 16 weeks, consider alternative treatments 2

Second-Line Biologic: Infliximab

• Infliximab 5 mg/kg at weeks 0,2,6, then every 8 weeks for patients unresponsive to adalimumab 1, 2
  • Higher doses (10 mg/kg) and more frequent intervals (every 4 weeks) supported for severe refractory cases 7
  • 78% of patients achieved ≥50% decrease in HS score in clinical trials 7
  • Suggested for pediatric patients ≥6 years 1

Other Biologics Under Investigation

• Secukinumab suggested for patients ≥6 years, with response rates of 64.5-71.4% in adalimumab-failure patients 1, 7
• Ustekinumab suggested for patients ≥6 years 1
• Etanercept is NOT recommended for moderate-to-severe HS 1

Hormonal Therapies (Adjunctive)

• Spironolactone for adolescent females requiring anti-androgens 1
• Combined oral contraceptives for adolescent females 1
• Finasteride in select cases, particularly male patients 1
• Metformin for patients with concomitant diabetes mellitus, females with polycystic ovary syndrome, or pregnancy 1

Surgical Interventions

Indications and Techniques

• Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring 1, 2, 6

• Deroofing for recurrent nodules and tunnels in localized disease 2, 6

• Extensive/radical excision to minimize recurrence rate when conventional systemic treatments have failed 1, 2

  • Width of excision influences therapeutic outcome 2

• Wound closure options: Secondary intention healing, TDAP (thoracodorsal artery perforator) flap for axillary wounds, skin grafts, or other reconstructive methods 1, 2, 6

Essential Adjunctive Measures

• Smoking cessation referral where relevant 1, 2
• Weight management referral where relevant 1, 2
• Pain management with NSAIDs for symptomatic relief 2, 6
• Appropriate wound dressings for draining lesions 1, 2, 6

Long-Term Monitoring

• Monitor for complications in long-standing moderate-to-severe HS: fistulating GI disease, inflammatory arthritis, genital lymphoedema, cutaneous squamous cell carcinoma, and anemia 1

Treatments NOT Recommended

• Isotretinoin unless concomitant moderate-to-severe acneiform lesions of face or trunk present 1, 6
• Cryotherapy due to pain from procedure 1, 2
• Microwave ablation 1, 2
• Adalimumab 40 mg every other week (insufficient dosing) 1
• Etanercept 1

Critical Pitfalls to Avoid

• Do not use doxycycline as first-line for Hurley Stage II with deep inflammatory lesions or abscesses—it has minimal effect on these lesions 2
• Do not continue antibiotics long-term without treatment breaks—this increases antimicrobial resistance risk 1, 2
• Do not use adalimumab 40 mg every other week—weekly dosing is required for moderate-to-severe HS 1, 5
• Do not delay dermatology referral for Hurley Stage III disease 1