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 per lesion) 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 pitfall: 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 2

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

• Moxifloxacin + metronidazole + rifampin for moderate-to-severe disease 1

Alternative systemic options:

• Dapsone 50-200 mg daily (titrate gradually) may be effective for minority of patients with Hurley Stage I-II as long-term maintenance 1

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

First-line biologic therapy:

• Adalimumab (FDA-approved for HS) 3:
  • Adults: 160 mg subcutaneous at week 0 (single dose or split over 2 consecutive days), 80 mg at week 2, then 40 mg weekly starting week 4 1, 2, 3
  • Adolescents ≥12 years: Same dosing as adults 3
  • Assess response at 16 weeks using HiSCR (≥50% reduction in inflammatory lesions); discontinue if no response 2

Second-line biologic therapy (if adalimumab fails):

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

Third-line biologic options (limited evidence):

• Secukinumab (IL-17 inhibitor): 64.5-71.4% response rate in adalimumab-failure patients at 16-52 weeks 2
• 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 dose can be considered as adjunct therapy in severe HS with suboptimal response 1
• Cyclosporine can be considered in recalcitrant moderate-to-severe HS who 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 evidence does NOT support methotrexate or azathioprine for HS treatment 1

Surgical Interventions

• Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring 1, 2
• Deroofing: For recurrent nodules and tunnels in localized disease 2
• Radical surgical excision: For extensive disease with sinus tracts and scarring 1, 2
  • Width of excision influences therapeutic outcome 2
  • Wound closure options: secondary intention healing, skin grafts, TDAP flap, or other reconstructive methods 2
• Critical consideration: Non-surgical methods rarely result in lasting cure for advanced disease 2

Pediatric Patients (≥12 Years)

• Adalimumab is FDA-approved for ages ≥12 years with moderate-to-severe HS 3:
  • Weight-based dosing: Same as adult dosing for patients ≥30 kg 1
• Doxycycline 100 mg once or twice daily for patients ≥8 years requiring systemic antibiotics 1, 2
• Critical pitfall: Avoid tetracyclines in children <9 years due to teeth staining risk 1
• Topical clindamycin 1% twice daily combined with antiseptic washes for mild disease 1, 4
• Screen every pediatric HS patient for metabolic syndrome, hormonal imbalances, and psychological comorbidities at diagnosis 4

Special Populations

Pregnancy

• Safe options 1:
  • Topical antibiotics (continue with similar approach)
  • Antiseptic washes: chlorhexidine, bleach baths, zinc pyrithione
  • Intralesional steroids for acute, localized flares
  • Oral cephalexin or azithromycin if systemic antibiotics needed
  • Zinc supplements
• Avoid: Resorcinol, triclosan, retinoids, hormonal agents, most systemic antibiotics, most immunosuppressants 1

History of Malignancy

• Consult with oncologist before initiating immunosuppressive medications or biologics 1
• Preferred anti-androgen: Metformin (strong recommendation due to safety and potential survival benefit) 1
• Biologics: Consider anti-TNFs if malignancy in remission >5 years; consider secukinumab or ustekinumab if malignancy within last 5 years 1

Treatment Monitoring and Reassessment

• Reassess at 12 weeks using 2:
  • HiSCR (Hidradenitis Suppurativa Clinical Response): ≥50% reduction in inflammatory lesions
  • Pain VAS score
  • Inflammatory lesion count
  • Quality of life measures (DLQI)
• Treatment escalation criteria: If no clinical response after 12 weeks of antibiotics, escalate to combination therapy or biologics 2
• Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 2

Essential Adjunctive Measures (All Patients)

• Smoking cessation referral (tobacco use associated with worse outcomes) 2
• Weight management referral if BMI elevated 2
• Pain management with NSAIDs for symptomatic relief 2, 4
• Appropriate wound dressings for draining lesions 2, 4
• 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 2
• Do NOT continue doxycycline beyond 4 months without reassessment due to antimicrobial resistance risk 2
• Do NOT use topical clindamycin alone without combining with benzoyl peroxide or antiseptic wash 2
• Do NOT use progestogen-only contraceptives as they may worsen HS 1
• Do NOT use etanercept for HS management (limited evidence does not support its use) 1
• Avoid long-term antibiotic use without treatment breaks to reduce antimicrobial resistance 2