What is the approach and management of hidradenitis suppurativa?

Approach and Management of Hidradenitis Suppurativa

Begin with topical clindamycin 1% twice daily for 12 weeks in mild disease (Hurley Stage I), escalate to oral clindamycin 300 mg plus rifampicin 600 mg daily for 10-12 weeks in moderate disease (Hurley Stage II), and initiate adalimumab for severe disease (Hurley Stage III) or after antibiotic failure. 1, 2

Initial Assessment and Diagnosis

Diagnostic Criteria:

• Confirm diagnosis by identifying typical lesions (inflamed nodules, open comedones, sinus tracts, bridging scars) in predominantly flexural locations (axillae, groins, perineum, inframammary areas) with chronicity (≥2 lesions in last 6 months or lifetime history of >5 lesions) 1
• Examine all intertriginous areas to determine total disease burden, not just the presenting site 2

Severity Staging:

• Record Hurley stage for the worst affected regions: Stage I (isolated nodules/abscesses without sinus tracts), Stage II (recurrent abscesses with sinus tracts and scarring, separated lesions), Stage III (diffuse involvement with multiple interconnected sinus tracts) 1, 2

Baseline Measurements:

• Document pain using Visual Analog Scale (VAS) 1, 2
• Count inflammatory lesions (nodules and abscesses) 1, 2
• Measure quality of life using Dermatology Life Quality Index (DLQI) 1, 2
• Screen for depression and anxiety 1, 2
• Screen for cardiovascular risk factors: measure blood pressure, lipids, and HbA1c 1, 2

Treatment Algorithm by Disease Severity

Hurley Stage I (Mild Disease)

First-Line Therapy:

• Topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks 1, 2
• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 2

Adjunctive Therapy for Acute Flares:

• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) for acutely inflamed nodules provides rapid symptom relief within 1 day 2, 3
• This is purely symptomatic and does not address underlying disease progression 3

If Inadequate Response After 12 Weeks:

• Add oral tetracycline: doxycycline 100 mg once or twice daily OR lymecycline 408 mg once or twice daily for 12 weeks 1, 2
• Can extend up to 16 weeks for more widespread mild disease 2

Hurley Stage II (Moderate Disease)

First-Line Therapy:

• Clindamycin 300 mg orally twice daily PLUS rifampicin 600 mg once daily (or 300 mg twice daily) for 10-12 weeks 1, 2
• This combination achieves response rates of 71-93%, far superior to tetracycline monotherapy 2
• Consider treatment break after completion to assess need for ongoing therapy and limit antimicrobial resistance 1, 2

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

If Inadequate Response After 12 Weeks:

• Escalate to adalimumab (see severe disease protocol below) 1, 2
• Consider surgical consultation for localized disease with deroofing procedures 1, 2

Hurley Stage III (Severe Disease) or Refractory Moderate Disease

First-Line Biologic Therapy:

• Adalimumab dosing for 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, 2, 4
• Adalimumab dosing for adolescents ≥12 years:
  • 30-60 kg: 80 mg day 1, then 40 mg every other week starting day 8 2, 4
  • ≥60 kg: Use adult dosing (160 mg/80 mg/40 mg weekly) 2, 4

Assess Response at 16 Weeks:

• Use Hidradenitis Suppurativa Clinical Response (HiSCR): ≥50% reduction in inflammatory lesion count with no increase in abscesses or draining fistulas 2, 5
• If no clinical response by 16 weeks, consider alternative biologics 2

Second-Line Biologic Options After Adalimumab Failure:

• Infliximab: 5 mg/kg at weeks 0,2,6, then every 8 weeks 2
• Secukinumab: Response rates of 64.5-71.4% in adalimumab-failure patients at 16-52 weeks 2
• Ustekinumab: Alternative targeting different cytokine pathways 2

Alternative Non-Biologic Options (If Biologics Contraindicated/Failed):

• Acitretin 0.3-0.5 mg/kg/day (only for males or non-fertile females due to teratogenicity) 1, 2
• Dapsone 50-200 mg daily (titrate gradually) 1, 2

Surgical Management

Indications for Surgery:

• Hurley Stage III disease with extensive sinus tracts and scarring 1, 2
• Localized recurrent nodules and tunnels amenable to deroofing 1, 2
• Failure of medical therapy with progressive fibrosis 1, 6

Surgical Options:

• Deroofing: For recurrent nodules and tunnels—removes roof of sinus tracts while preserving base 2, 7
• Radical surgical excision: For extensive disease with wide margins; healing by secondary intention, skin grafts, or thoracodorsal artery perforator (TDAP) flaps 1, 2
• Refer to hidradenitis suppurativa surgical multidisciplinary team for extensive excision planning 1

Critical Point:

• Surgery is often necessary for lasting cure in advanced disease, as non-surgical methods rarely result in lasting cure once fibrosis and sinus tracts have formed 2, 6

Essential Adjunctive Management (All Patients, All Stages)

Lifestyle Modifications:

• Smoking cessation referral (smoking has odds ratio of 3.6 for HS) 1, 2
• Weight management referral if BMI elevated (obesity has odds ratio of 3.3 for HS) 1, 2

Pain Management:

• NSAIDs for symptomatic relief 1, 2
• Assess pain at every visit using VAS 1, 2

Wound Care:

• Provide appropriate dressings for pus-producing and draining lesions 1, 2

Comorbidity Screening:

• Screen for depression/anxiety at baseline and follow-up 1, 2
• Screen for cardiovascular risk factors: measure BP, lipids, HbA1c (nearly doubled risk of cardiovascular death in HS patients) 1, 2
• Screen for metabolic syndrome, type 2 diabetes, inflammatory bowel disease 1, 8

Monitoring and Reassessment

At 12-Week Follow-Up:

• Measure pain VAS score 1, 2
• Count inflammatory lesions and number of flares in last month 1, 2
• Reassess quality of life using DLQI 1, 2

Treatment Escalation Criteria:

• Lack of response at 12 weeks warrants escalation to next treatment tier 1, 2
• For Hurley Stage III, consider immediate referral to dermatology and initiation of clindamycin-rifampicin or adalimumab without delay 1, 2

Critical Pitfalls to Avoid

• Do not use doxycycline monotherapy for Hurley Stage II disease with abscesses—it lacks efficacy for deep inflammatory lesions 2
• Do not continue antibiotics indefinitely without treatment breaks—increases antimicrobial resistance risk 1, 2
• Do not use intralesional steroids as monotherapy—they provide only temporary symptomatic relief and do not address disease progression 3
• Do not delay biologic therapy in severe disease—early intervention prevents irreversible skin damage with tunnel formation and scarring 8
• Do not overlook cardiovascular screening—HS patients have significantly elevated cardiovascular mortality 1

Treatments with Insufficient Evidence (Not Recommended)

The following therapies lack sufficient evidence and are not recommended: alitretinoin, anakinra, apremilast, azathioprine, ciclosporin, colchicine, methotrexate, oral prednisolone, phototherapy, cryotherapy, and microwave ablation 2