Hidradenitis Suppurativa Treatment
For hidradenitis suppurativa, treatment selection is determined by Hurley stage: topical clindamycin 1% twice daily for 12 weeks for mild disease (Stage I), clindamycin 300 mg plus rifampicin 300-600 mg orally twice daily for 10-12 weeks for moderate disease (Stage II), and adalimumab 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting week 4 for severe disease (Stage III) or after antibiotic failure. 1, 2, 3
Disease Severity Assessment
Determine Hurley stage for the worst-affected anatomical region to guide treatment selection: Stage I (isolated nodules/abscesses without sinus tracts), Stage II (recurrent abscesses with sinus tracts and scarring in single or multiple areas), Stage III (diffuse involvement with multiple interconnected sinus tracts and abscesses). 1, 2, 4
Measure baseline pain using Visual Analog Scale (VAS) and count inflammatory lesions (abscesses and nodules) to establish treatment response metrics. 2, 4
Screen for comorbidities including depression/anxiety, diabetes, hypertension, hyperlipidemia, inflammatory bowel disease, and inflammatory arthritis, as systemic inflammation drives these associations. 2, 4, 5
Hurley Stage I (Mild Disease)
Topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks is first-line therapy, reducing pustules though carrying high bacterial resistance risk. 1, 2, 4
Combine topical clindamycin with antiseptic washes (chlorhexidine 4%, benzoyl peroxide, or zinc pyrithione) daily to reduce Staphylococcus aureus colonization and antimicrobial resistance risk. 1, 2, 4
Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) provides rapid symptom relief within 1 day for acutely inflamed nodules, showing significant reduction in erythema, edema, suppuration, and pain. 1, 2, 4
Resorcinol 15% cream reduces pain and abscess duration but commonly causes irritant contact dermatitis. 1, 2
If topical therapy fails after 12 weeks, escalate to oral tetracyclines: doxycycline 100 mg once or twice daily for 12-16 weeks or lymecycline 408 mg once or twice daily for 12 weeks. 1, 2, 4
Hurley Stage II (Moderate Disease)
Clindamycin 300 mg orally twice daily plus rifampicin 300-600 mg orally once or twice daily for 10-12 weeks is first-line therapy, demonstrating response rates of 71-93% and significantly superior efficacy compared to tetracycline monotherapy. 1, 2, 4
This combination is effective as second-line treatment for mild-to-moderate disease or as first-line/adjunct treatment in severe disease, and can be repeated intermittently. 1
Continue topical clindamycin 1% and antiseptic washes as adjunctive therapy during systemic antibiotic treatment. 2, 4
Doxycycline monotherapy is NOT recommended as first-line for Stage II disease with abscesses or inflammatory nodules, as it demonstrates minimal effect on these deep lesions with only 30% abscess reduction in trials. 2
If clindamycin-rifampicin fails after 10-12 weeks, consider triple therapy with moxifloxacin, metronidazole, and rifampin as second- or third-line treatment. 1
IV ertapenem 1g daily for 6 weeks is recommended for severe disease as rescue therapy or bridge to surgery/long-term maintenance. 1, 2
Hurley Stage III (Severe Disease)
Adalimumab is first-line biologic therapy: 160 mg at week 0 (single dose or split over two consecutive days), 80 mg at week 2, then 40 mg weekly starting week 4, achieving HiSCR response rates of 42-59% at week 12. 1, 2, 4, 3
For adolescents 12 years and older weighing 30-60 kg: 80 mg on day 1, then 40 mg every other week starting day 8; for those ≥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). 2, 3
Assess treatment response at 12 weeks using HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas); if no clinical response by week 16, consider alternative treatments. 2, 4, 3
If adalimumab fails, infliximab 5 mg/kg at weeks 0,2,6, then every 8 weeks is second-line biologic therapy, with higher doses and more frequent intervals supported for severe refractory cases. 1, 2, 4
Secukinumab demonstrates response rates of 64.5-71.4% in adalimumab-failure patients at 16-52 weeks and can be used as alternative biologic targeting IL-17 pathway. 2
Ustekinumab is suggested as alternative biologic option after adalimumab failure, targeting IL-12/23 pathways. 2
Surgical Interventions
Wide local excision (radical surgical excision) is definitive treatment for extensive disease with sinus tracts and scarring, as non-surgical methods rarely result in lasting cure for advanced disease. 1, 2, 4
Deroofing is appropriate for recurrent nodules and tunnels in localized disease without extensive scarring. 1, 2
Wound closure options include secondary intention healing (preferred for contaminated wounds), TDAP flap, delayed primary closure, skin grafts, or tissue substitutes depending on defect size and location. 1, 2, 4
Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy for extensive disease. 2
Hormonal Therapies (Appropriate Female Patients)
Hormonal agents including estrogen-containing combined oral contraceptives, spironolactone, cyproterone acetate, metformin, and finasteride should be considered as monotherapy for mild-to-moderate HS or in combination with other agents for severe disease. 1
Progestogen-only contraceptives may worsen HS and should potentially be avoided based on anecdotal data. 1
Metformin is recommended for patients with history of malignancy due to evidence of safety and potential survival benefit in certain malignancies. 1
Immunosuppressants and Retinoids
Available limited evidence does not support the use of methotrexate or azathioprine in HS treatment. 1
Acitretin 0.3-0.5 mg/kg/day is an alternative option for patients unresponsive to adalimumab, though teratogenicity must be considered in females of reproductive age. 2, 6
Dapsone starting at 50 mg daily and titrating up to 200 mg daily may be effective for minority of patients with Hurley stage I or II disease as long-term maintenance therapy. 1, 2
Short-term pulse steroid therapy (oral prednisone) can be considered for acute flares or to bridge patients to other treatment, but long-term systemic corticosteroids should be tapered to lowest possible dose. 1
Treatment Response Assessment
Reassess at 12 weeks using HiSCR (≥50% reduction in inflammatory lesion count with no increase in abscesses or draining fistulas), pain VAS score, and Dermatology Life Quality Index (DLQI). 2, 4
Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance. 2
Recurrence following antibiotic cessation is frequent; duration and frequency of antibiotic use should balance benefit received with risk of antibiotic resistance. 1
Essential Adjunctive Measures
Refer all patients to smoking cessation services, as tobacco use has odds ratio of 36 for HS and is associated with worse outcomes. 2, 4
Refer patients with obesity to weight management services, as obesity has odds ratio of 33 for HS. 2, 4
Pain management with NSAIDs for symptomatic relief; consider opioids for severe pain. 2, 4
Select wound dressings based on drainage amount, anatomical location, and patient preference for draining lesions. 2, 4
Special Population Considerations
For pregnancy: topical clindamycin, cephalexin, azithromycin, and clindamycin are safe; avoid resorcinol due to potential fetal neurodevelopment risks. 1
For patients with history of malignancy in remission >5 years: consider anti-TNFs especially in non-high-risk malignancies; for malignancy within last 5 years, consider secukinumab or ustekinumab based on limited evidence. 1
Screen for latent TB prior to initiating biologics using TST and/or IGRA; if positive, start 4-month course of oral rifampin before starting biologic. 1
Critical Pitfalls to Avoid
Do NOT use doxycycline as first-line for Hurley Stage II with deep inflammatory lesions or abscesses, as it has minimal effect on these lesions. 2
Do NOT continue antibiotics long-term without treatment breaks, as this increases antimicrobial resistance risk without proven additional benefit. 2, 4
Do NOT rely on topical clindamycin monotherapy for Stage II or III disease, as it is insufficient for moderate-to-severe disease. 1, 2
Do NOT delay surgical referral for Stage III disease with extensive sinus tracts, as medical therapy alone rarely achieves lasting cure in advanced disease. 1, 2, 4