What is the treatment for hidradenitis suppurativa?

Hidradenitis Suppurativa Treatment

For hidradenitis suppurativa, treatment should be stratified by disease severity using the Hurley staging system: 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 at week 0,80 mg at week 2, then 40 mg weekly starting week 4) for severe or antibiotic-refractory disease (Hurley Stage III). 1, 2

Disease Severity Assessment

• Determine Hurley stage to guide treatment selection: Stage I (isolated nodules/abscesses without sinus tracts), Stage II (recurrent abscesses with sinus tracts and scarring, widely separated lesions), Stage III (diffuse involvement with multiple interconnected sinus tracts and scarring). 1, 2
• Document baseline inflammatory lesion count, pain using Visual Analog Scale, and quality of life using Dermatology Life Quality Index (DLQI). 1
• Examine all intertriginous areas (axillae, groin, inframammary, perianal) to assess total disease burden. 1

Treatment Algorithm by Disease Severity

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
• Combine with antiseptic washes (chlorhexidine 4%, benzoyl peroxide, or zinc pyrithione) daily to reduce Staphylococcus aureus colonization and antibiotic resistance risk. 1
• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) for acutely inflamed nodules provides rapid symptom relief within 1 day. 1
• If inadequate response after 12 weeks, escalate to oral tetracyclines: doxycycline 100 mg once or twice daily OR lymecycline 408 mg once or twice daily for 12 weeks. 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
• This combination achieves response rates of 71-93%, far superior to tetracycline monotherapy (30% abscess reduction). 1, 3
• Reassess at 12 weeks using HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas). 1
• 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. 1
• If no response after 12 weeks of clindamycin-rifampicin, escalate to adalimumab. 1

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

• First-line biologic: Adalimumab 160 mg subcutaneously at week 0 (single dose or split over 2 consecutive days), 80 mg at week 2, then 40 mg weekly starting week 4. 1, 4
• Adalimumab is FDA-approved for moderate-to-severe HS in patients ≥12 years old. 4
• HiSCR response rates: 42-59% at week 12 in PIONEER trials. 5
• If no response after 16 weeks of adalimumab, consider second-line biologics: 1
  • Infliximab 5 mg/kg IV at weeks 0,2,6, then every 2 months 1
  • Secukinumab (response rates 64.5-71.4% in adalimumab-failure patients) 1
  • Ustekinumab 1

Adolescent Dosing (12 Years and Older)

• For adolescents 30-60 kg: 80 mg on Day 1, then 40 mg every other week starting Day 8. 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). 4

Surgical Interventions

• Deroofing for recurrent nodules and tunnels in localized disease. 1, 2
• Radical surgical excision for extensive disease with sinus tracts and scarring, with healing by secondary intention, skin grafts, or flaps. 1, 2
• Surgery combined with adalimumab results in greater clinical effectiveness than adalimumab monotherapy for advanced disease. 1
• Non-surgical methods rarely result in lasting cure for advanced disease—surgery is often necessary for definitive treatment. 2, 6

Essential Adjunctive Measures (All Patients)

• Smoking cessation referral—tobacco use is associated with worse outcomes. 1, 2
• Weight loss for patients with obesity—obesity worsens disease severity. 1, 2
• Pain management with NSAIDs for symptomatic relief. 1, 2
• Appropriate wound dressings for draining lesions. 1
• Screen for depression/anxiety—quality of life is profoundly affected. 1, 6, 7
• Screen for cardiovascular risk factors (blood pressure, lipids, HbA1c) and comorbidities (diabetes, inflammatory bowel disease, metabolic syndrome). 1, 7

Monitoring and Treatment Response

• Assess response at 12 weeks using HiSCR (≥50% reduction in inflammatory lesions with no increase in abscesses or draining fistulas). 1, 2
• Monitor pain reduction using Visual Analog Scale and quality of life improvement using DLQI. 1, 2, 5
• For adalimumab: 40% of initial non-responders at week 12 may achieve response by week 36 with continued treatment, but almost half of week 12 responders lose response by week 36 despite continued weekly dosing. 5
• Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance. 1

Critical Pitfalls to Avoid

• Do not continue doxycycline beyond 4 months without reassessment—prolonged use increases antimicrobial resistance risk without proven additional benefit. 1
• Do not use topical clindamycin alone long-term without benzoyl peroxide—this increases Staphylococcus aureus resistance rates. 1
• Do not delay escalation to biologics in severe disease—early intervention prevents irreversible skin damage with tunnel formation and scarring. 7
• Avoid cryotherapy and microwave ablation during acute phase—these are not recommended. 1

Therapies with Insufficient Evidence

The following therapies lack sufficient evidence for recommendation: alitretinoin, anakinra, apremilast, azathioprine, ciclosporin, colchicine, methotrexate, oral prednisolone, phototherapy, radiotherapy, and many others. 1