What are the treatment options for Hidradenitis suppurativa?

Treatment of Hidradenitis Suppurativa

For mild disease (Hurley Stage I), start with topical clindamycin 1% twice daily for 12 weeks; for moderate disease (Hurley Stage II), use clindamycin 300 mg plus rifampicin 600 mg orally for 10-12 weeks; and for severe or refractory disease, escalate directly to adalimumab with loading doses of 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting week 4. 1, 2, 3

Disease Severity Assessment

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

• Hurley Stage I (Mild): Isolated nodules and abscesses without sinus tracts or scarring 3
• Hurley Stage II (Moderate): Recurrent abscesses with sinus tract formation and scarring, separated by normal skin 1
• Hurley Stage III (Severe): Diffuse involvement with multiple interconnected sinus tracts and abscesses across entire anatomic area 1

Document baseline pain using Visual Analog Scale (VAS) and inflammatory lesion count, and assess quality of life impact using the Dermatology Life Quality Index (DLQI) 1, 2. Screen all patients for comorbidities including depression/anxiety, diabetes, hypertension, hyperlipidemia, and inflammatory bowel disease 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, 2.

Adjunctive options: Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) for acutely inflamed nodules provides rapid symptom relief within 1 day, with significant reduction in erythema, edema, suppuration, and pain 1, 2.

Alternative for widespread mild disease: Tetracycline 500 mg orally twice daily for up to 4 months, or doxycycline 100 mg once or twice daily for 12-16 weeks 1, 2, 3. However, tetracyclines demonstrate only modest 30% abscess reduction and are not independently linked to better outcomes 2.

Moderate Disease (Hurley Stage II)

First-line therapy: Clindamycin 300 mg orally twice daily plus rifampicin 600 mg orally once daily (or 300 mg twice daily) for 10-12 weeks 1, 2, 3. This combination achieves response rates of 71-93%, far superior to tetracycline monotherapy 1, 2. Treatment can be repeated intermittently as needed 1, 2.

Critical pitfall: Do not use doxycycline monotherapy as first-line for Hurley Stage II with abscesses or deep inflammatory nodules, as it has minimal effect on these lesions 2. The clindamycin-rifampicin combination is the superior choice for this stage 2.

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.

Adult dosing 1, 2, 4:

• Day 1: 160 mg (given in one day or split over two consecutive days)
• Day 15: 80 mg
• Day 29 and thereafter: 40 mg weekly

Adolescent dosing (12 years and older) 1, 4:

• 30-60 kg: Day 1: 80 mg; Day 8 and thereafter: 40 mg every other week
• ≥60 kg: Same as adult dosing

Adalimumab demonstrates HiSCR response rates (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) of 42-59% at week 12 1, 2. If no clinical response after 16 weeks, consider alternative treatments 2.

Second-line biologic options after adalimumab failure 1, 2:

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

Surgical Interventions

Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring 1, 2, 3. Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 2.

Surgical options 1, 2:

• Deroofing: For recurrent nodules and tunnels
• Radical surgical excision: For extensive disease with sinus tracts and scarring, with non-recurrence rates of 81.25% after wide excision 1
• Wound closure options: Secondary intention healing, skin grafts, or flaps 2

The extent of surgical excision influences therapeutic outcome, with wider excisions associated with better long-term results 1, 2.

Essential Adjuvant Therapies for All Patients

Regardless of disease severity, all patients require 1, 2, 3:

• Smoking cessation referral: Tobacco use is associated with worse outcomes 1, 2, 3
• Weight management referral if BMI elevated: Weight loss is critical for disease management 1, 3
• Pain management: NSAIDs for symptomatic relief 1, 2
• Appropriate wound dressings for draining lesions 1, 2
• Screen for depression/anxiety and cardiovascular risk factors (blood pressure, lipids, HbA1c) 2, 3

Monitoring and Treatment Escalation

Reassess all patients at 12 weeks using 1, 2:

• Pain VAS score
• Inflammatory lesion count
• DLQI
• HiSCR for patients on biologic therapy

Escalation pathway if inadequate response after 12 weeks 1, 2:

1. If topical clindamycin fails → escalate to clindamycin 300 mg + rifampicin 600 mg orally for 10-12 weeks
2. If clindamycin-rifampicin fails → escalate to adalimumab
3. If adalimumab fails → consider infliximab, secukinumab, or ustekinumab

Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 2. Do not continue antibiotics beyond 4 months without reassessment, as prolonged use increases antimicrobial resistance risk without proven additional benefit 2.

Critical Warnings for Adalimumab

Adalimumab carries a boxed warning for serious infections (including tuberculosis, bacterial sepsis, invasive fungal infections) and malignancy (including lymphoma and hepatosplenic T-cell lymphoma in adolescents and young adults) 4. Perform latent tuberculosis testing before initiating adalimumab; if positive, start tuberculosis treatment prior to starting adalimumab 4. Monitor all patients for active tuberculosis during treatment, even if initial latent tuberculosis test is negative 4.