What are the management options for hidradenitis suppurativa (HS) by stage?

Hidradenitis Suppurativa Management by Hurley Stage

Management of hidradenitis suppurativa must be stratified by Hurley stage, with mild disease (Stage I) treated with topical clindamycin and oral tetracyclines, moderate disease (Stage II) requiring combination clindamycin-rifampicin, and severe disease (Stage III) necessitating weekly adalimumab or surgical excision. 1

Initial Assessment for All Stages

Before initiating stage-specific therapy, document the following baseline parameters:

• Record Hurley stage for the worst-affected anatomical region (axillae, groin, perineum, inframammary) 1
• Measure pain using Visual Analog Scale (VAS) and inflammatory lesion count 1
• Assess quality of life using Dermatology Life Quality Index (DLQI) 1
• Screen for comorbidities: depression, anxiety, diabetes, hypertension, hyperlipidemia, central obesity, and inflammatory bowel disease if gastrointestinal symptoms present 1
• Refer to smoking cessation services (smoking has odds ratio of 36 for HS) 1
• Refer to weight management services (obesity has odds ratio of 33 for HS) 1

Hurley Stage I (Mild Disease): Isolated Nodules/Abscesses Without Sinus Tracts

First-Line Treatment

• Topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks 1, 2
• Combine with antiseptic wash (chlorhexidine 4%, benzoyl peroxide, or zinc pyrithione) daily to reduce Staphylococcus aureus colonization and antimicrobial resistance risk 1, 2
• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) for acutely inflamed nodules, providing rapid symptom relief within 1 day 1, 2

Second-Line Treatment (if inadequate response at 12 weeks)

• Oral tetracycline: doxycycline 100 mg once or twice daily OR lymecycline 408 mg once or twice daily for 12 weeks 1, 2
• Reassess at 12 weeks using pain VAS, inflammatory lesion count, and DLQI 1, 2
• Consider treatment breaks after 12-16 weeks to assess need for ongoing therapy and limit antimicrobial resistance 1

Critical Pitfall: Do not use doxycycline monotherapy as first-line for Stage I disease with multiple inflammatory nodules—it shows only 30% abscess reduction and no significant improvement in patient-reported outcomes 2

Hurley Stage II (Moderate Disease): Recurrent Abscesses with Sinus Tracts and Scarring

First-Line Treatment

• 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 response rates of 71-93%, far superior to tetracycline monotherapy 2
• Continue topical clindamycin 1% and antiseptic washes as adjunctive therapy 1, 2
• Intralesional triamcinolone 10 mg/mL for individual inflamed lesions during acute flares 1

Critical Pitfall: Do not use doxycycline as first-line for Hurley Stage II with abscesses or deep inflammatory nodules—it has minimal effect on these lesions 2

Second-Line Treatment (if inadequate response at 12 weeks)

• Acitretin 0.3-0.5 mg/kg/day (for males and non-fertile females only) 1
• Dapsone starting at 50 mg daily, titrating up to 200 mg daily 1, 2
• Assess response after 12 weeks using HiSCR (≥50% reduction in abscess and inflammatory nodule count with no increase in abscess or draining fistula count) 1, 3

Procedural Interventions for Stage II

• Deroofing for recurrent nodules and tunnels 1
• Nd:YAG laser therapy for follicular destruction in Hurley Stage II disease (based on RCT data) 1
• CO2 laser excision for fibrotic sinus tracts 1

Hurley Stage III (Severe Disease): Diffuse Involvement with Multiple Interconnected Sinus Tracts

For Hurley Stage III disease, consider immediate referral to dermatology secondary care 1

First-Line Biologic Therapy

• Adalimumab (FDA-approved for HS in patients ≥12 years): 1, 3
  • Adults: 160 mg at Week 0 (single dose or split over 2 consecutive days), 80 mg at Week 2, then 40 mg weekly starting Week 4 1, 3
  • Adolescents 60 kg and greater: Same as adult dosing 3
  • Adolescents 30-60 kg: 80 mg at Day 1, then 40 mg every other week starting Day 8 3
• HiSCR response rates: 42-59% at Week 12 (vs. 26-28% placebo) 3
• Assess response at 12 weeks using HiSCR; if no clinical response by Week 16, consider alternative treatments 1, 2, 3
• Continue adalimumab perioperatively if surgical intervention planned—experience suggests minimal risk of increased postoperative complications 1

Critical Evidence: Do NOT use adalimumab 40 mg every other week for moderate-to-severe HS—this dosing is ineffective (strong recommendation against) 1

Second-Line Biologic Therapy (after adalimumab failure)

• Infliximab 5 mg/kg at weeks 0,2,6, then every 8 weeks 1, 2
• Secukinumab (conditional recommendation, moderate quality evidence): response rates 64.5-71.4% in adalimumab-failure patients at 16-52 weeks 1, 2
• Ustekinumab (conditional recommendation, moderate quality evidence) for patients ≥6 years 1, 2

Surgical Interventions for Stage III

• Wide local excision (radical surgical excision) for extensive disease with sinus tracts and scarring 1, 2
• Wound closure options: 1
  • Secondary intention healing (preferred for most sites)
  • TDAP (thoracodorsal artery perforator) flap for axillary wounds
  • Delayed primary closure
  • Skin grafts or substitutes
• Negative-pressure therapy for selected large open wounds for 1-4 weeks followed by delayed reconstruction 1
• Continue medical therapy perioperatively to minimize recurrence 1

Critical Pitfall: Do NOT perform simple incision and drainage as definitive treatment—recurrence rates approach 100%, though it may provide temporary pain relief for acute abscesses 1, 4

Adjunctive Therapies for All Stages

• Pain management: NSAIDs for symptomatic relief; consider opioids for severe pain 1, 4
• Wound dressings: Select based on drainage amount, anatomical location, and patient preference 1, 4
• Warm compresses to affected areas for symptomatic relief 4
• Loose-fitting cotton clothing to minimize friction (16% of patients report worsening from tight clothing) 4
• Metformin for patients with concomitant diabetes mellitus, polycystic ovary syndrome, or pregnancy 1

Treatment Response Assessment Timeline

• Reassess at 12 weeks for all medical therapies using: 1, 2
  • Pain VAS score
  • Inflammatory lesion count
  • Number of flares in last month
  • DLQI
  • HiSCR (for biologic therapy)
• For adalimumab: If no clinical response by Week 16, discontinue and consider alternative biologics or surgery 1, 2, 3

Long-Term Monitoring for Moderate-to-Severe HS

• Monitor for: fistulating gastrointestinal disease, inflammatory arthritis, genital lymphoedema, cutaneous squamous cell carcinoma, and anemia 1, 4
• Annual TB screening if on glucocorticoids >15 mg prednisone equivalent daily for ≥4 weeks 1
• TB screening prior to biologic initiation using TST and/or IGRA 1

Therapies with Insufficient Evidence or Strong Recommendations Against

• Do NOT offer: isotretinoin (unless concomitant moderate-to-severe facial/truncal acne), etanercept, cryotherapy, or microwave ablation 1
• Insufficient evidence to recommend: anakinra, apremilast, azathioprine, ciclosporin, methotrexate, oral prednisolone, photodynamic therapy, radiotherapy, or hyperbaric oxygen 1