Hidradenitis Suppurativa Treatment Algorithm
For hidradenitis suppurativa, treatment selection depends on 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 twice daily for 10-12 weeks for moderate disease (Hurley Stage II), and adalimumab with loading dose 160 mg followed by 80 mg then 40 mg weekly for severe or refractory disease (Hurley Stage III). 1, 2, 3
Disease Severity Assessment
Determine Hurley stage at initial presentation by examining all intertriginous areas (axillae, groin, inframammary, genitoanal regions) to assess for isolated nodules/abscesses (Stage I), recurrent nodules with sinus tracts (Stage II), or diffuse involvement with multiple interconnected tracts and scarring (Stage III). 1, 3
Document baseline inflammatory lesion count, pain using Visual Analog Scale (VAS), and quality of life impact using Dermatology Life Quality Index (DLQI) to establish treatment response metrics. 1, 3
Screen for comorbidities including depression/anxiety, diabetes (HbA1c), hypertension (blood pressure), hyperlipidemia (lipid panel), and inflammatory bowel disease, as these frequently accompany HS due to systemic inflammation. 1, 4
Mild Disease (Hurley Stage I): Isolated Nodules Without Sinus Tracts
First-line therapy is topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks. 1, 2, 3
Combine topical clindamycin with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk, as topical clindamycin monotherapy increases resistance rates. 1, 3
For acutely inflamed nodules requiring rapid symptom relief, inject intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion), which reduces erythema, edema, suppuration, and pain within 1 day. 1
If topical therapy fails 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, 2
Moderate Disease (Hurley Stage II): Recurrent Nodules with Sinus Tracts
First-line systemic therapy is 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, 3
This combination is superior to tetracycline monotherapy (which shows only 30% abscess reduction) and is the preferred regimen for Hurley Stage II disease with deep inflammatory lesions. 1
Do NOT use doxycycline monotherapy as first-line for Hurley Stage II with abscesses or inflammatory nodules, as it has minimal effect on these lesions. 1
Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance development. 1
Reassess at 12 weeks using pain VAS score, inflammatory lesion count, and DLQI; if inadequate response, escalate to adalimumab. 1, 3
Severe or Refractory Disease (Hurley Stage III or Failed Antibiotics)
First-line biologic therapy is adalimumab with FDA-approved dosing: 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, 3, 5
Adalimumab is FDA-approved for moderate-to-severe HS in patients ≥12 years old, with HiSCR response rates (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) of 42-59% at week 12. 1, 5
For adolescents 12 years and older weighing 30-60 kg: 80 mg on Day 1, then 40 mg every other week starting Day 8. 5
For adolescents ≥60 kg: use adult dosing (160 mg, 80 mg, then 40 mg weekly OR 80 mg every other week). 5
Assess treatment response at 12 weeks using HiSCR; if no clinical response after 16 weeks, consider alternative biologics. 1
Second-Line Biologic Options After Adalimumab Failure
Infliximab 5 mg/kg at weeks 0,2,6, then every 2 months is the preferred second-line biologic for adalimumab failures. 1, 2
Secukinumab (IL-17 inhibitor) demonstrates response rates of 64.5-71.4% in adalimumab-failure patients at 16-52 weeks and targets different inflammatory pathways than TNF-alpha. 1, 4, 6
Ustekinumab (IL-12/23 inhibitor) is an alternative second-line option with conditional strength and moderate quality evidence for patients ≥6 years old. 1
For treatment-refractory disease, consider dual biologic therapy combining secukinumab with infliximab to target multiple inflammatory pathways simultaneously. 1
Surgical Interventions
Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring, as non-surgical methods rarely result in lasting cure for Hurley Stage III. 1, 2, 3
Deroofing is appropriate for recurrent nodules and tunnels without extensive scarring, preserving surrounding tissue. 1, 2
Radical surgical excision with wide margins is recommended for extensive disease with multiple interconnected sinus tracts and morbid scarring, with non-recurrence rates of 81.25% after wide excision. 1, 3
Wound closure options include healing by secondary intention, skin grafts, TDAP flap, or other reconstructive methods depending on defect size and location. 1
Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy for extensive disease. 1
Adjunctive Therapies (Essential for All Patients)
Smoking cessation referral is mandatory, as tobacco use is associated with worse outcomes and increased disease severity. 1, 2, 3
Weight loss referral for patients with elevated BMI, as obesity is associated with increased HS severity and is a modifiable risk factor. 2, 3, 4
Pain management with NSAIDs for symptomatic relief of inflammatory pain. 1, 3
Appropriate wound dressings for draining lesions to prevent secondary infection and improve quality of life. 1, 3
Critical Pitfalls to Avoid
Do NOT continue doxycycline beyond 4 months without reassessment, as prolonged use increases antimicrobial resistance risk without proven additional benefit. 1
Do NOT use doxycycline as first-line for Hurley Stage II with deep inflammatory lesions or abscesses, as evidence shows only 30% abscess reduction with no significant improvement in patient-reported outcomes. 1
Do NOT use cryotherapy or microwave ablation for treating lesions during the acute phase, as guidelines recommend against these modalities. 1
Do NOT delay escalation to biologics in patients with progressive disease despite adequate antibiotic trials, as early intervention prevents irreversible skin damage with tunnel formation and morbid scarring. 4
Treatments with Insufficient Evidence
There is insufficient evidence to recommend alitretinoin, anakinra, apremilast, atorvastatin, azathioprine, ciclosporin, colchicine, cyproterone, finasteride, fumaric acid esters, methotrexate, oral prednisolone, phototherapy, or radiotherapy for HS treatment. 1
Acitretin 0.3-0.5 mg/kg/day and dapsone (50-200 mg daily) are alternative options for patients unresponsive to adalimumab, though evidence quality is limited. 1, 7
Ertapenem 1g daily for 6 weeks can be considered as rescue therapy or during surgical planning for severe disease requiring IV antibiotics. 1