What are the treatment options for hidradenitis suppurativa?

Hidradenitis Suppurativa Treatment

Treat hidradenitis suppurativa using a severity-based algorithm: topical clindamycin 1% twice daily for 12 weeks for mild disease (Hurley Stage I), clindamycin 300 mg plus rifampicin 300-600 mg orally twice daily for 10-12 weeks for moderate disease (Hurley Stage II), and adalimumab (160 mg week 0,80 mg week 2, then 40 mg weekly starting week 4) for severe or refractory disease (Hurley Stage III or antibiotic failure). 1, 2, 3

Disease Severity Assessment

• Determine Hurley stage first to guide treatment selection: Stage I (isolated nodules/abscesses without sinus tracts), Stage II (recurrent abscesses with sinus tracts and scarring, widely separated), Stage III (diffuse involvement with multiple interconnected sinus tracts). 1, 2
• Document baseline inflammatory lesion count, pain using Visual Analog Scale (VAS), and quality of life using Dermatology Life Quality Index (DLQI) before initiating therapy. 1, 3
• Screen all patients for comorbidities including depression/anxiety, diabetes, hypertension, hyperlipidemia, and inflammatory bowel disease at initial assessment. 1

Mild Disease (Hurley Stage I)

• First-line: Topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks. 1, 2, 3
• Combine topical clindamycin with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk—this is critical as topical clindamycin monotherapy increases resistance rates. 1
• For inflamed nodules requiring rapid relief: Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) provides symptom reduction within 1 day. 1
• If topical therapy fails or disease is more widespread: Escalate to oral doxycycline 100 mg once or twice daily OR lymecycline 408 mg once or twice daily for 12 weeks. 1

Critical Pitfall for Mild Disease

• Doxycycline monotherapy shows only modest efficacy (30% abscess reduction in the single available RCT) and should not be used as first-line for any disease with deep inflammatory lesions or abscesses. 1

Moderate Disease (Hurley Stage II)

• First-line: Clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 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
• Treatment duration is typically 8-12 weeks and can be repeated intermittently as needed. 1
• Alternative if clindamycin-rifampicin unavailable: Tetracycline 500 mg twice daily for up to 4 months, though this is significantly less effective. 1

When to Escalate from Moderate Disease Treatment

• Reassess at 12 weeks using pain VAS, inflammatory lesion count, and DLQI. 1, 3
• If inadequate response after 12 weeks of oral antibiotics, escalate to adalimumab or consider surgical intervention. 1
• Do not continue antibiotics beyond 4 months without reassessment—prolonged use increases antimicrobial resistance without proven additional benefit. 1

Severe or Refractory Disease (Hurley Stage III or Antibiotic Failure)

• First-line biologic: Adalimumab with loading dose of 160 mg at week 0 (can split over two consecutive days), 80 mg at week 2, then 40 mg weekly starting week 4. 1, 2, 3, 4
• Adalimumab is FDA-approved for moderate to severe hidradenitis suppurativa in patients 12 years and older. 4
• Assess response using Hidradenitis Suppurativa Clinical Response (HiSCR) at 12-16 weeks—if no clinical response by 16 weeks, switch to alternative therapy. 1, 2

Second-Line Biologic Options After Adalimumab Failure

• Infliximab 5 mg/kg at weeks 0,2,6, then every 2 months for patients who fail adalimumab, with higher doses and more frequent intervals supported for severe refractory cases. 1
• Secukinumab demonstrates response rates of 64.5-71.4% in adalimumab-failure patients at 16-52 weeks (conditional recommendation, moderate quality evidence). 1
• Ustekinumab is an alternative targeting different cytokines than TNF-alpha (conditional recommendation, moderate quality evidence). 1

Rescue Therapy for Severe Disease

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

Surgical Interventions

• Surgery is often necessary for lasting cure, especially in advanced disease—non-surgical methods rarely result in lasting cure for Hurley Stage II-III. 1, 2
• For recurrent nodules and tunnels: Deroofing procedure (unroofing of sinus tracts). 1
• For extensive disease with sinus tracts and scarring: Radical surgical excision with healing by secondary intention, skin grafts, or flap reconstruction. 1, 2
• The width of excision influences therapeutic outcome—studies show non-recurrence rates of 81.25% after wide excision. 3

Adolescent Dosing (12 Years and Older)

• For adolescents 30-60 kg: 80 mg day 1, then 40 mg every other week starting day 8. 1, 4
• For adolescents ≥60 kg: Use adult dosing (160 mg day 1,80 mg day 15, then 40 mg weekly OR 80 mg every other week starting day 29). 1, 4

Essential Adjunctive Measures (All Patients)

• Smoking cessation referral—tobacco use is associated with significantly worse outcomes. 1, 2, 5
• Weight management referral if BMI elevated—obesity is a major risk factor. 1, 2, 6
• Pain management with NSAIDs for symptomatic relief. 1, 2
• Appropriate wound dressings for draining lesions. 1, 7
• Screen for cardiovascular risk factors: Measure blood pressure, lipids, and HbA1c at baseline. 1

Therapies with Insufficient Evidence (Do Not Use)

The British Journal of Dermatology states there is insufficient evidence to recommend: alitretinoin, anakinra, apremilast, atorvastatin, azathioprine, ciclosporin, colchicine, cyproterone, finasteride, fumaric acid esters, methotrexate, oral prednisolone, phototherapy, radiotherapy, or spironolactone. 1

Treatment Monitoring Algorithm

• At 12 weeks: Reassess using pain VAS, inflammatory lesion count, DLQI, and HiSCR (for biologic therapy). 1, 2, 3
• For antibiotics: Consider treatment break after courses to assess need for ongoing therapy and limit antimicrobial resistance. 1
• For adalimumab: If no response by 16 weeks, switch to alternative biologic or consider surgical intervention. 1, 2