What are the treatment options for Hidradenitis suppurativa?

Treatment Options for Hidradenitis Suppurativa

Treatment of hidradenitis suppurativa follows a severity-based stepwise approach: topical clindamycin 1% twice daily for mild disease (Hurley Stage I), combination oral clindamycin 300 mg plus rifampicin 300-600 mg daily for 10-12 weeks for moderate disease (Hurley Stage II), and adalimumab 160 mg/80 mg/40 mg weekly for severe or refractory disease (Hurley Stage III). 1, 2, 3

Initial Assessment and Disease Staging

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

• Hurley Stage I (Mild): Isolated nodules and abscesses without sinus tracts or scarring 3
• 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 scarring across entire anatomical region 1, 4

Document baseline pain using Visual Analog Scale (VAS), inflammatory lesion count, and quality of life using Dermatology Life Quality Index (DLQI) 1, 2, 3. Screen all patients for depression, anxiety, cardiovascular risk factors (blood pressure, lipids, HbA1c), inflammatory bowel disease, and metabolic syndrome 1, 4, 3.

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I)

First-line therapy is topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks. 1, 2, 3

• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 2
• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) can be injected into acutely inflamed nodules for rapid symptom relief within 1 day 2
• Alternative oral option: doxycycline 100 mg once or twice daily for 12 weeks or lymecycline 408 mg once or twice daily for 12 weeks 1, 2

Critical caveat: Tetracyclines as monotherapy have weak evidence, with only 30% reduction in abscesses and no significant improvement in patient-reported outcomes 2. They should not be used as first-line for disease with deep inflammatory lesions 2, 4.

Moderate Disease (Hurley Stage II)

First-line therapy is clindamycin 300 mg orally twice daily plus rifampicin 300-600 mg orally once or twice daily for 10-12 weeks. 1, 2, 4, 3

This combination achieves response rates of 71-93%, far superior to tetracycline monotherapy 2, 4. Treatment can be repeated intermittently after a treatment break to assess need for ongoing therapy and limit antimicrobial resistance 1, 2.

If inadequate response after 12 weeks of tetracyclines, escalate immediately to clindamycin-rifampicin combination 2. Do not continue ineffective antibiotics beyond 12 weeks, as prolonged use increases antimicrobial resistance without proven additional benefit 4.

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

First-line biologic therapy is adalimumab with the following dosing schedule: 2, 4, 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 2, 4, 5
• Adolescents 12 years and older weighing 30-60 kg: 80 mg on Day 1, then 40 mg every other week starting Day 8 5
• Adolescents 12 years and older weighing ≥60 kg: Same as adult dosing 5

Adalimumab achieves HiSCR (Hidradenitis Suppurativa Clinical Response) rates of 42-59% at week 12, with a number needed to treat of 4 4. This is the only FDA-approved biologic for hidradenitis suppurativa 5, 6.

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

Alternative systemic options for patients unresponsive to adalimumab: 1, 2

• Acitretin 0.3-0.5 mg/kg/day (for males and non-fertile females only) 1
• Dapsone 50-200 mg daily 1, 2
• Ertapenem 1g daily IV for 6 weeks as rescue therapy 2

Surgical Interventions

Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring. 2, 3, 7

Surgical options include 1, 2, 3:

• Deroofing: For recurrent nodules and tunnels 2, 3
• Radical surgical excision: For extensive disease with sinus tracts and scarring, with healing by secondary intention, skin grafts, TDAP flaps, or other reconstructive methods 1, 2, 3

Refer to hidradenitis suppurativa surgical multidisciplinary team for Hurley Stage III disease, lack of response to medical therapy after 12 weeks, or recurrent nodules amenable to deroofing 1, 4.

Essential Adjunctive Measures

Regardless of disease severity, address the following 1, 2, 4:

• Smoking cessation referral: Tobacco use is associated with worse outcomes and predicts poor antibiotic response 4, 3
• Weight management referral: Obesity (BMI elevated) is strongly associated with disease severity 1, 3
• Pain management: NSAIDs for symptomatic relief 1, 2
• Appropriate wound dressings: For draining lesions 1, 2
• Screen for comorbidities: Depression, anxiety, cardiovascular risk factors, inflammatory bowel disease, metabolic syndrome 1, 4, 3, 8

Treatment Monitoring and Response Assessment

Reassess at 12 weeks using 1, 2, 3:

• Pain VAS score 1, 2
• Inflammatory lesion count 1, 2
• Quality of life measures (DLQI) 1, 2
• HiSCR (≥50% reduction in inflammatory lesion count with no increase in abscesses or draining fistulas) 2, 3

For adalimumab, if clinical response is not achieved after 16 weeks, consider alternative treatments 2. Discontinue ulcerative colitis treatment without evidence of clinical remission by 8 weeks (Day 57), though this applies to UC indication specifically 5.

Critical Pitfalls to Avoid

• Do not use doxycycline as first-line for Hurley Stage II with abscesses or deep inflammatory lesions, as it has minimal effect on these lesions 2, 4
• Do not use tetracyclines as first-line for severe flares, as they are ineffective for deep inflammatory lesions and sinus tracts 4
• Do not continue ineffective antibiotics beyond 12 weeks without reassessment, as this increases antimicrobial resistance risk 2, 4
• Do not use adalimumab 40 mg every other week (insufficient dosing) 3
• Do not offer isotretinoin unless there are concomitant moderate-to-severe acneiform lesions of face or trunk 3
• Do not offer etanercept, cryotherapy during acute phase, or microwave ablation 3

Treatments with Insufficient Evidence

The British Association of Dermatologists states there is insufficient evidence to recommend: alitretinoin, anakinra, apremilast, atorvastatin, azathioprine, ciclosporin, colchicine, cyproterone, finasteride, fumaric acid esters, hydrocortisone, hyperbaric oxygen therapy, intravenous antibiotics, isoniazid, laser and photodynamic therapies, methotrexate, oral prednisolone, oral zinc, phototherapy, photochemotherapy, radiotherapy, spironolactone, staphage lysate, tolmetin sodium, and ustekinumab 2.