What are the treatment options for hidradenitis suppurativa?

Hidradenitis Suppurativa Treatment Options

For hidradenitis suppurativa, treatment selection is determined by Hurley staging: 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). 1, 2, 3

Initial Assessment and Disease Staging

Before initiating treatment, determine disease severity using the Hurley staging system 1, 2, 3:

• Hurley Stage I (Mild): Isolated nodules and abscesses without sinus tracts or scarring 2
• Hurley Stage II (Moderate): Recurrent abscesses with sinus tract formation and scarring 2
• Hurley Stage III (Severe): Diffuse involvement with multiple interconnected sinus tracts and extensive scarring 2

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

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I)

First-line therapy: 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 1.

Adjunctive therapy: Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) for acutely inflamed nodules provides rapid symptom relief within 1 day, with significant reduction in erythema, edema, suppuration, and pain 1.

Alternative options: Resorcinol 15% cream can reduce pain and duration of abscesses, though irritant dermatitis is a common side effect 1.

Moderate Disease (Hurley Stage II)

First-line therapy: Clindamycin 300 mg orally twice daily plus rifampicin 300-600 mg orally once or twice daily for 10-12 weeks, with response rates of 71-93% 1, 2. This combination is far superior to tetracycline monotherapy 1.

Alternative first-line: Oral tetracyclines (doxycycline 100 mg once or twice daily OR lymecycline 408 mg once or twice daily OR tetracycline 500 mg twice daily) for 12-16 weeks for more widespread mild disease 1, 2. However, 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 1, 2.

Treatment breaks: Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1.

Reassessment at 12 weeks: If inadequate response after 12 weeks of tetracyclines, escalate to clindamycin-rifampicin combination 1, 2. If no response to clindamycin-rifampicin after 12 weeks, escalate to adalimumab 1.

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

First-line biologic therapy: Adalimumab is FDA-approved for moderate to severe hidradenitis suppurativa in patients 12 years and older 4:

• 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 1, 2, 4
• Adolescents 60 kg and greater: Same as adult dosing 4
• Adolescents 30-60 kg: 80 mg on Day 1, then 40 mg every other week starting Day 8 4

HiSCR response rates: 42-59% at week 12, defined as ≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas 1, 2.

Treatment duration: If no clinical response after 16 weeks, consider alternative treatments 1. Discontinue in patients without evidence of clinical remission by 8 weeks (Day 57) for ulcerative colitis indication, though this specific timeline is not established for HS 4.

Second-line biologic options after adalimumab failure:

• Infliximab: 5 mg/kg at weeks 0,2,6, then every 2 months 1, 2
• Secukinumab: Response rates of 64.5-71.4% in adalimumab-failure patients at 16-52 weeks 1
• Ustekinumab: Alternative biologic option with conditional strength and moderate quality evidence 1

Alternative systemic options for patients unresponsive to adalimumab:

• Acitretin: 0.3-0.5 mg/kg/day 1
• Dapsone: Starting at 50 mg daily, titrating up to 200 mg daily 1
• Ertapenem: 1g daily IV for 6 weeks as rescue therapy or during surgical planning 1

Surgical Interventions

Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring 1, 2, 5:

• Deroofing: For recurrent nodules and tunnels 1
• Radical surgical excision: For extensive disease with sinus tracts and scarring, with width of excision influencing therapeutic outcome 1, 2
• Wound closure options: Secondary intention healing, skin grafts, TDAP flap, or other reconstructive methods 1, 2

Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 1. Refer patients with Hurley Stage III disease or lack of response to medical therapy after 12 weeks to a hidradenitis suppurativa surgical multidisciplinary team 2.

Essential Adjunctive Measures

These should be implemented regardless of disease severity 1, 2, 3:

• Smoking cessation referral: Tobacco use is associated with worse outcomes and predicts poor antibiotic response 1, 2, 3
• Weight management referral: Obesity is strongly associated with disease severity 1, 2, 3
• Pain management: NSAIDs for symptomatic relief 1, 2
• Appropriate wound dressings: For draining lesions 1, 2
• Screen for depression/anxiety: Quality of life is profoundly affected 1, 2, 5
• Screen for cardiovascular risk factors: Measure blood pressure, lipids, HbA1c 1, 2

Treatment Monitoring and Response Assessment

Reassess at 12 weeks using 1, 2:

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

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 1, 2
• Do not use tetracyclines as first-line for severe flares, as they are ineffective for deep inflammatory lesions and sinus tracts 2
• Do not continue ineffective antibiotics beyond 12 weeks without reassessment, as this increases antimicrobial resistance risk 1, 2
• Do not use adalimumab 40 mg every other week (insufficient dosing) 3
• Do not offer cryotherapy or microwave ablation to treat lesions during the acute phase 1, 3
• Do not offer isotretinoin unless there are concomitant moderate-to-severe acneiform lesions of the face or trunk 3
• Do not offer etanercept 3

Treatments with Insufficient Evidence

The British Journal of Dermatology 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 1.

Special Populations

Pediatric patients 12 years and older: Adalimumab is FDA-approved with weight-based dosing 1, 4.

Pediatric patients 8 years and older requiring systemic antibiotics: Oral doxycycline is recommended 1.

Pregnant patients: Metformin for those requiring anti-androgens; adalimumab for those requiring biologics 3.