What are the treatment options for hidradenitis suppurativa?

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 by examining all intertriginous areas (axillae, groin, inframammary, perianal) to assess for isolated nodules/abscesses (Stage I), recurrent nodules with sinus tracts and scarring in single or multiple areas (Stage II), or diffuse involvement with multiple interconnected sinus tracts and scarring (Stage III). 1, 2, 4

• Document baseline inflammatory lesion count (abscesses and inflammatory nodules), pain using Visual Analog Scale (0-10), and quality of life using Dermatology Life Quality Index (DLQI). 2, 4

• Screen for comorbidities including depression/anxiety, diabetes (HbA1c), hypertension (blood pressure), hyperlipidemia (lipid panel), inflammatory bowel disease, and inflammatory arthritis. 2, 4

Hurley Stage I (Mild Disease)

• First-line: Topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks. 1, 2

• Combine with antiseptic washes—chlorhexidine 4%, benzoyl peroxide, or zinc pyrithione—applied daily to reduce Staphylococcus aureus colonization and minimize antibiotic resistance risk. 1, 2

• For acutely inflamed nodules, inject intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) to achieve rapid symptom relief within 24 hours. 1, 2

• If topical therapy fails after 12 weeks, escalate to oral tetracyclines: doxycycline 100 mg once or twice daily for 12 weeks, or lymecycline 408 mg once or twice daily for 12 weeks. 1, 2

Hurley Stage II (Moderate Disease)

• First-line: 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

• Continue topical clindamycin 1% and antiseptic washes as adjunctive therapy during systemic antibiotic treatment. 2, 4

• Reassess at 12 weeks using HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas), pain VAS, and DLQI. 1, 2, 4

• If inadequate response after 12 weeks, escalate to triple therapy: moxifloxacin, metronidazole, and rifampin for 12 weeks as second- or third-line treatment. 1

• Alternative for minority of patients: dapsone starting at 50 mg daily, titrating up to 200 mg daily for long-term maintenance in Hurley Stage I or II disease. 1

Hurley Stage III (Severe Disease) or Refractory Cases

• First-line biologic: Adalimumab 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, with HiSCR response rates of 42-59% at week 12. 1, 2, 3

• Assess response at 12 weeks using HiSCR; if no clinical response by week 16, consider alternative biologics. 2, 3

• Second-line biologic: Infliximab 5 mg/kg IV at weeks 0,2,6, then every 8 weeks for patients who fail adalimumab. 1, 2

• Alternative biologics after adalimumab failure: Secukinumab (response rates 64.5-71.4% in adalimumab-failure patients at 16-52 weeks) or ustekinumab, both with conditional strength and moderate quality evidence. 1, 2

• For severe disease requiring IV antibiotics, use ertapenem 1 g IV daily for 6 weeks as rescue therapy or bridge to surgery/long-term maintenance. 1

Surgical Interventions

• For recurrent nodules and tunnels without extensive scarring, perform deroofing (unroofing of sinus tracts) as a tissue-sparing procedure. 1, 2

• For extensive disease with multiple interconnected sinus tracts and scarring (Hurley Stage III), perform radical surgical excision of all affected tissue, with width of excision influencing therapeutic outcome. 1, 2

• Wound closure options include secondary intention healing, TDAP flap, delayed primary closure, skin grafts, or skin substitutes depending on defect size and location. 2, 4

• Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy for extensive disease. 2

Hormonal Therapy (Appropriate Female Patients)

• Consider hormonal agents as monotherapy for mild-to-moderate disease or in combination with other agents for severe disease: estrogen-containing combined oral contraceptives, spironolactone, cyproterone acetate, metformin, or finasteride. 1

• Avoid progestogen-only contraceptives as anecdotal data suggest they may worsen HS. 1

Adjunctive Measures (All Stages)

• Refer to smoking cessation services immediately, as smoking has an odds ratio of 36 for HS and worsens outcomes. 2, 4

• Refer to weight management services if BMI elevated, as obesity has an odds ratio of 33 for HS. 2, 4

• Manage pain 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

Pediatric Considerations

• For adolescents 12 years and older with moderate-to-severe HS, adalimumab is FDA-approved with weight-based dosing: 30-60 kg receive 80 mg on day 1, then 40 mg every other week starting day 8; ≥60 kg receive adult dosing (160 mg day 1,80 mg day 15, then 40 mg weekly or 80 mg every other week starting day 29). 1, 3

• For children 8 years and older requiring systemic antibiotics, use oral doxycycline with appropriate weight-based dosing. 2

Critical Pitfalls to Avoid

• 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; clindamycin-rifampicin is superior. 1, 2

• Do not continue antibiotics indefinitely without treatment breaks, as this increases antimicrobial resistance risk without proven additional benefit. 1

• Do not combine topical clindamycin alone long-term without benzoyl peroxide or antiseptic washes, as this increases Staphylococcus aureus resistance rates. 1, 2

• Do not delay biologic therapy in patients with progressive Hurley Stage III disease, as chronic inflammation leads to irreversible skin damage with tunnel formation and morbid scarring. 5

• Screen for latent tuberculosis with TST and/or IGRA prior to initiating biologics; if positive, start 4-month course of oral rifampin before biologic initiation. 1

Long-Term Monitoring

• Monitor patients with moderate-to-severe disease for fistulating gastrointestinal disease, inflammatory arthritis, genital lymphedema, cutaneous squamous cell carcinoma, and anemia. 4

• Perform annual TB screening if patients are on glucocorticoids >15 mg prednisone equivalent daily for ≥4 weeks. 1, 4

• Recurrence following antibiotic cessation is frequent; determine duration and frequency of antibiotic use by balancing benefit received with risk of antibiotic resistance. 1