What is the best source for treating hydradenitis suppurativa?

Hidradenitis Suppurativa Treatment: Evidence-Based Approach

For patients with hidradenitis suppurativa, treatment selection depends on disease severity using the Hurley staging system, with topical clindamycin 1% for mild disease, oral clindamycin plus rifampicin for moderate disease, and adalimumab for severe or refractory cases, combined with essential adjunctive measures including smoking cessation, weight management, and surgical intervention when indicated. 1, 2

Disease Assessment and Staging

Determine Hurley stage to guide treatment selection:

• 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 scarring 1

Assess baseline metrics before initiating therapy:

• Document pain using Visual Analog Scale (VAS) 1, 2
• Count inflammatory lesions (nodules, abscesses, draining tunnels) 2
• Measure quality of life impact using Dermatology Life Quality Index (DLQI) 1
• Screen for comorbidities: depression/anxiety, diabetes, hypertension, hyperlipidemia, inflammatory bowel disease 1, 2

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

Critical adjunctive measures:

• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 2, 4
• Consider intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) for acutely inflamed nodules, providing rapid symptom relief within 1 day 1, 2

Alternative for more widespread mild disease:

• Tetracycline 500 mg orally twice daily for up to 4 months 1
• Doxycycline 100 mg orally once or twice daily for 12 weeks 1, 2
• Lymecycline 408 mg orally once or twice daily for 12 weeks 1, 2

Important caveat: Tetracycline monotherapy showed only 30% reduction in abscesses with no significant improvement in patient-reported outcomes compared to topical clindamycin 2

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 1, 2

This combination demonstrates superior efficacy:

• Response rates of 71-93% in systematic reviews 2, 3
• Significantly better outcomes for abscesses and inflammatory nodules characteristic of Hurley Stage II 2
• Can be repeated intermittently as needed 1, 2

Do NOT use doxycycline monotherapy as first-line for Hurley Stage II with deep inflammatory lesions or abscesses, as it has minimal effect on these lesions 2

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

First-line biologic therapy: Adalimumab with FDA-approved dosing 1, 2, 5

Dosing schedule:

• Week 0: 160 mg subcutaneously (single dose or split over two consecutive days)
• Week 2: 80 mg subcutaneously
• Week 4 onward: 40 mg subcutaneously weekly 1, 5

Expected outcomes:

• HiSCR response rates of 42-59% at week 12 2
• Significant improvements in pain (VAS), quality of life (DLQI), and work productivity 1
• Maintain therapy as long as HS lesions are present if improvement occurs 1

If adalimumab fails after 16 weeks, consider second-line biologic options:

• Infliximab: 5 mg/kg IV 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 2
• Ustekinumab: Alternative targeting different cytokine pathways 2

For treatment-refractory disease, dual biologic therapy (secukinumab plus infliximab) may be considered, targeting different inflammatory pathways 2

Surgical Interventions

Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring 1, 2, 3

Surgical options based on disease extent:

• Deroofing: For recurrent nodules and tunnels without extensive scarring 2, 3
• Radical surgical excision: For extensive disease with multiple interconnected sinus tracts 1, 6
• Wound closure options: Secondary intention healing (preferred), TDAP flap for axillary wounds, or skin grafts 1, 2

Critical principle: The width of excision influences therapeutic outcome, with non-recurrence rates of 81.25% after wide excision 3

Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 2

Essential Adjunctive Measures for ALL Patients

These interventions directly impact morbidity and quality of life:

• Smoking cessation referral: Tobacco use is strongly associated with worse outcomes and disease progression 1, 2, 3
• Weight management referral if BMI elevated: Obesity worsens disease severity 1, 2, 3
• Pain management: NSAIDs for symptomatic relief 1, 2
• Appropriate wound dressings for draining lesions 1, 2
• Screen and treat superinfections as they arise 1

Monitoring and Treatment Reassessment

Reassess at 12 weeks using objective measures:

• HiSCR (Hidradenitis Suppurativa Clinical Response): ≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas 1, 2, 3
• Pain VAS score 2, 3
• Inflammatory lesion count 2, 3
• DLQI 2, 3

Treatment escalation pathway if inadequate response after 12 weeks:

1. Mild disease on topical clindamycin → Escalate to oral tetracyclines or clindamycin-rifampicin 2
2. Moderate disease on tetracyclines → Escalate to clindamycin-rifampicin 2
3. Moderate disease on clindamycin-rifampicin → Escalate to adalimumab 1, 2
4. Severe disease on adalimumab → Consider second-line biologics or surgical intervention 2

Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1, 2

Critical Pitfalls to Avoid

• Do NOT offer adalimumab 40 mg every other week (instead of weekly) for moderate-to-severe HS unresponsive to conventional therapy—this dosing is inadequate 1
• Do NOT offer etanercept for moderate-to-severe HS unresponsive to conventional therapy—insufficient efficacy 1
• Do NOT offer isotretinoin unless there are concomitant moderate-to-severe acneiform lesions of the face or trunk 1
• Do NOT offer cryotherapy due to excessive pain from the procedure 1
• Do NOT use mupirocin as treatment for HS—it is a topical decolonization agent for nasal MRSA carriage, not a treatment for the chronic inflammatory disease process 4
• Do NOT continue doxycycline beyond 4 months without reassessment, as prolonged use increases antimicrobial resistance risk without proven additional benefit 2

Special Populations

Adolescents 12 years and older with moderate-to-severe disease:

• Adalimumab is FDA-approved with weight-based dosing 2, 5
• For patients ≥40 kg: Same dosing as adults (160 mg → 80 mg → 40 mg weekly) 5

Pediatric patients 6 years and older with Crohn's disease pattern:

• Oral doxycycline is recommended for those requiring systemic antibiotics 2

1, 2, 4, 3, 5