What are the treatment options for episodic hidradenitis?

Treatment of Episodic Hidradenitis Suppurativa

For episodic (mild, Hurley Stage I) hidradenitis suppurativa, start with topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks, combined with daily antiseptic washes containing benzoyl peroxide or chlorhexidine 4% to reduce antibiotic resistance risk. 1, 2

Initial Assessment and Disease Staging

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

• Hurley Stage I (episodic/mild): Isolated nodules and abscesses without sinus tracts or scarring 3
• Document baseline pain using Visual Analog Scale (VAS) 1
• Count inflammatory lesions (nodules and abscesses) 1
• Assess quality of life impact using Dermatology Life Quality Index (DLQI) 1

First-Line Topical Therapy for Episodic Disease

Topical clindamycin 1% is the cornerstone of treatment for mild, episodic disease:

• Apply twice daily to all affected intertriginous areas for 12 weeks 1, 2
• Critical pitfall: Topical clindamycin monotherapy increases Staphylococcus aureus resistance rates 1
• Always combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to mitigate resistance development 1

Acute Flare Management

For acutely inflamed nodules during episodic flares:

• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) provides rapid symptom relief within 1 day 1
• Significantly reduces erythema, edema, suppuration, and pain 1
• Can be repeated as needed for individual inflammatory lesions 1

When to Escalate to Oral Antibiotics

If topical therapy fails after 12 weeks or disease progresses beyond isolated nodules:

First-line oral antibiotic options:

• Doxycycline 100 mg once or twice daily for 12 weeks 1
• Alternative: Lymecycline 408 mg once or twice daily for 12 weeks 1
• Alternative: Tetracycline 500 mg twice daily for up to 4 months 1

Important limitation: Doxycycline monotherapy shows only modest efficacy (30% abscess reduction) and is not recommended for Hurley Stage II disease with deep inflammatory lesions or abscesses 1

Second-Line Systemic Therapy

If no clinical response after 12 weeks of tetracyclines, escalate to:

• Clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg daily for 10-12 weeks 1, 2
• This combination demonstrates superior efficacy with response rates of 71-93% 1, 2
• Can be repeated intermittently after treatment breaks to assess ongoing need and limit antimicrobial resistance 1

Reassessment at 12 Weeks

Evaluate treatment response using:

• Pain VAS score 1
• Inflammatory lesion count 1
• DLQI score 1
• For patients on biologics: HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) 1

Essential Adjunctive Measures for All Patients

Regardless of pharmacologic treatment chosen:

• Smoking cessation referral (tobacco use worsens outcomes) 1, 3
• Weight management referral if BMI elevated 1, 3
• Pain management with NSAIDs for symptomatic relief 1, 3
• Appropriate wound dressings for any draining lesions 1
• Screen for depression/anxiety 1
• Screen for cardiovascular risk factors (blood pressure, lipids, HbA1c) 1

When to Refer to Dermatology

Refer for specialist evaluation if:

• No response after 12 weeks of clindamycin-rifampicin combination 1
• Disease progresses to Hurley Stage II or III 1
• Development of sinus tracts, tunnels, or extensive scarring 4
• Consideration needed for biologic therapy (adalimumab) or surgical intervention 1

Critical Pitfalls to Avoid

• Do not use topical clindamycin without concurrent antiseptic washes due to resistance risk 1
• Do not continue antibiotics indefinitely without treatment breaks to reduce antimicrobial resistance 1
• Do not use doxycycline as first-line for disease beyond isolated nodules (Hurley Stage II) 1
• Do not offer isotretinoin, etanercept, or cryotherapy as these are not effective for HS 4