What is the recommended treatment for hidradenitis suppurativa?

Hidradenitis Suppurativa Treatment

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

Disease Severity Assessment

• Determine disease severity using the Hurley staging system before initiating treatment 2:

  • Hurley Stage I: Isolated nodules and 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 sinus tracts and abscesses across entire anatomic area

• Examine all intertriginous areas (axillae, groin, inframammary, perianal) to determine total disease burden 2

• Document baseline pain using Visual Analog Scale and count inflammatory lesions 2

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I)

First-line topical therapy:

• Topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks 1, 2
• Combine with antiseptic washes (chlorhexidine 4%, benzoyl peroxide, or zinc pyrithione) daily to reduce Staphylococcus aureus resistance risk 2
• Critical pitfall: Topical clindamycin alone increases rates of S. aureus resistance; always combine with benzoyl peroxide or antiseptic wash 2

Adjunctive procedures:

• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) for acutely inflamed nodules provides rapid symptom relief within 1 day 2
• Resorcinol 15% cream can reduce pain and duration of abscesses, though irritant dermatitis is common 2

First-line oral antibiotics (if topical therapy inadequate):

• Doxycycline 100 mg once or twice daily for 12 weeks 1, 2
• Alternative: Lymecycline 408 mg once or twice daily for 12 weeks 2
• Alternative: Tetracycline 500 mg twice daily for up to 4 months 1
• Important limitation: Tetracyclines show only modest 30% reduction in abscesses with weak evidence quality 2

Moderate Disease (Hurley Stage II)

First-line combination antibiotic therapy:

• Clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg orally once or twice daily for 10-12 weeks 1, 2
• This combination demonstrates 71-93% response rates, far superior to tetracycline monotherapy 2
• Treatment can be repeated intermittently as needed 1
• Critical point: This is the superior first-line choice for Hurley Stage II disease with abscesses and inflammatory nodules 2

Second-line triple antibiotic therapy (if clindamycin-rifampicin fails):

• Moxifloxacin, metronidazole, and rifampin in combination 1

Alternative long-term maintenance:

• Dapsone starting at 50 mg daily, titrating up to 200 mg daily for minority of patients with Hurley Stage I-II disease 1, 2

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

First-line biologic therapy:

• Adalimumab (FDA-approved for HS) 1, 3:
  • Week 0: 160 mg (single dose or split over two consecutive days)
  • Week 2: 80 mg
  • Week 4 onward: 40 mg weekly
  • Assess response at 16 weeks using HiSCR (≥50% reduction in inflammatory lesions) 2
  • If no clinical response by 16 weeks, consider alternative treatments 2

Second-line biologic therapy:

• Infliximab 5 mg/kg at weeks 0,2,6, then every 2 months for patients who fail adalimumab 1
• Higher doses and more frequent intervals supported for severe refractory cases 2

Emerging biologic options (conditional recommendations):

• Secukinumab (IL-17 inhibitor): 64.5-71.4% response rate in adalimumab-failure patients at 16-52 weeks 2, 4
• Ustekinumab 45-90 mg every 12 weeks may be effective but requires placebo-controlled dose-ranging studies 1
• Anakinra 100 mg daily may be effective but requires dose-ranging studies 1
• Important: Limited evidence does NOT support etanercept for HS management 1

Rescue therapy for severe disease:

• IV ertapenem 1g daily for 6 weeks as one-time rescue therapy or bridge to surgery/long-term maintenance 1, 2

Hormonal Therapies (Appropriate Female Patients)

• Consider as monotherapy for mild-to-moderate HS or in combination with other agents for severe disease 1:

  • Estrogen-containing combined oral contraceptives 1
  • Spironolactone 1
  • Metformin 1
  • Finasteride 1
  • Cyproterone acetate 1

• Critical pitfall: Progestogen-only contraceptives may worsen HS and should be avoided 1

Immunosuppressants (Limited Evidence)

• Short-term pulse prednisone for acute, widespread flares or to bridge patients to other treatment 1
• Long-term systemic corticosteroids tapered to lowest possible dose as adjunct therapy in severe HS with suboptimal response 1
• Cyclosporine can be considered in recalcitrant moderate-to-severe HS who have failed or are not candidates for standard therapy 1
• Acitretin 0.3-0.5 mg/kg/day as alternative for patients unresponsive to adalimumab 2
• Important: Available limited evidence does NOT support methotrexate or azathioprine in HS treatment 1

Surgical Interventions

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

Surgical options by extent:

• Deroofing: For recurrent nodules and tunnels in localized disease 2, 5
• Radical surgical excision: For extensive disease with sinus tracts and scarring 1, 2
• Wound closure options: Secondary intention healing, skin grafts, TDAP flap, or other reconstructive methods 2
• Critical point: Width of excision influences therapeutic outcome 2

Treatment Monitoring and Reassessment

• Reassess at 12 weeks using 2:

  • Pain VAS score
  • Inflammatory lesion count (HiSCR: ≥50% reduction)
  • Quality of life measures (DLQI)

• Treatment escalation criteria:

  • If inadequate response after 12 weeks of tetracyclines, escalate to clindamycin-rifampicin combination 2
  • If no response after 12 weeks of clindamycin-rifampicin, consider triple antibiotic therapy or biologics 2
  • If no clinical response to adalimumab by 16 weeks, consider infliximab or alternative biologics 2

• Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 2

Special Populations

Pediatric Patients (≥12 years)

• Adalimumab is FDA-approved for ages ≥12 years with moderate to severe HS 5, 3:

  • Weight-based dosing for adolescents
  • 30 kg and greater: 40 mg every other week initially, may increase to weekly if needed

• Doxycycline 100 mg once or twice daily for patients ≥8 years old (avoid in children <9 years due to teeth staining risk) 1, 5

• Topical clindamycin 1% twice daily combined with antiseptic washes for mild disease 5

• Screen every pediatric HS patient for metabolic syndrome, hormonal imbalances, and psychological comorbidities at diagnosis 5

Pregnant Patients

• Safe options 1:

  • Topical antibiotics (approach similar to other HS populations)
  • Chlorhexidine, bleach baths, zinc pyrithione antiseptic washes
  • Zinc supplements (strong recommendation, moderate quality evidence)
  • Intralesional steroids for acute, localized flares
  • Oral cephalexin (moderate quality evidence)
  • Oral azithromycin (moderate quality evidence)

• Avoid 1:

  • Resorcinol (lacking safety evidence)
  • Triclosan (endocrine-disrupting effects)
  • Retinoids
  • Hormonal agents
  • Most systemic antibiotics
  • Most immunosuppressive medications

Patients with History of Malignancy

• Consult with oncologist and consider HS activity, patient age, cancer characteristics (organ, stage, histology, prognosis), time since cancer treatment completion, and individual carcinogenic effects of immunosuppressants 1

Safe antibiotic options:

• Oral clindamycin (monitor for C. difficile colitis) 1
• Oral dapsone 1
• IV ertapenem for severe, recalcitrant cases 1

Safe anti-androgen options:

• Metformin (strong recommendation due to safety and potential survival benefit in certain malignancies) 1
• Spironolactone 1
• Oral contraceptives 1
• Finasteride 1

Biologic considerations:

• Malignancy in remission >5 years: Consider anti-TNFs especially in non-high-risk malignancies 1
• Malignancy in last 5 years: Consider secukinumab or ustekinumab based on limited evidence 1

Essential Adjunctive Measures (All Patients)

• Smoking cessation referral (tobacco use associated with worse outcomes) 2
• Weight management referral if BMI elevated (obesity is risk factor) 2
• Pain management with NSAIDs for symptomatic relief 2, 5
• Appropriate wound dressings for draining lesions 2, 5
• Screen for comorbidities 2:
  • Depression/anxiety
  • Cardiovascular risk factors (blood pressure, lipids, HbA1c)
  • Diabetes mellitus
  • Inflammatory bowel disease
  • Metabolic syndrome

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 doxycycline beyond 4 months without reassessment—increases antimicrobial resistance risk without proven additional benefit 2
• Do NOT use topical clindamycin alone without antiseptic wash—increases S. aureus resistance 2
• Do NOT use progestogen-only contraceptives—may worsen HS 1
• Do NOT use cryotherapy or microwave ablation during acute phase 2
• Avoid long-term antibiotic use without treatment breaks to reduce antimicrobial resistance 2