What treatment approach is recommended for a patient with stage 3 hidradenitis suppurativa (HS) when antibiotics are not warranted?

Treatment Approach for Stage 3 Hidradenitis Suppurativa Without Antibiotics

For stage 3 HS when antibiotics are not warranted, the primary treatment strategy should be extensive surgical excision combined with biologic therapy, specifically adalimumab, as this represents the only FDA-approved medication for moderate-to-severe HS and addresses the severe inflammatory burden characteristic of Hurley stage III disease. 1, 2

Surgical Management as Primary Intervention

• Extensive excision should be strongly considered for stage 3 HS to minimize recurrence rates, particularly when conventional systemic treatments have failed or are not appropriate 1
• Secondary intention healing or TDAP (thoracodorsal artery perforator) flap closure for axillary wounds should be considered following extensive excision 1
• Surgery becomes increasingly important in stage 3 disease, as medical management alone rarely achieves adequate disease control at this severity level 1

Biologic Therapy: First-Line Systemic Option

Adalimumab 40 mg weekly (or 80 mg every other week after loading) is the recommended biologic therapy for stage 3 HS, as it is FDA-approved for moderate-to-severe HS in patients 12 years and older 2

Dosing Protocol for Adalimumab:

• Loading dose: 160 mg on Day 1 (can be split over two consecutive days), followed by 80 mg on Day 15 2
• Maintenance: 40 mg every other week starting Day 29, though some patients may benefit from weekly dosing 2

Alternative Biologics:

• Infliximab can be considered as an alternative biologic for stage 3 HS, though it lacks FDA approval for this indication 1, 3
• Secukinumab (anti-IL-17) may be considered, though caution is advised in patients with personal or family history of inflammatory bowel disease 1
• Ustekinumab (anti-IL-12/23) represents another option under investigation, though evidence remains limited 1

Important Caveat About Adalimumab Dosing

The British guidelines specifically recommend AGAINST adalimumab 40 mg every other week for moderate-to-severe HS unresponsive to conventional therapy 1, suggesting this lower-frequency dosing may be insufficient. This underscores the importance of either weekly dosing or the higher every-other-week dose (80 mg) for severe disease.

Adjunctive Medical Therapies

Pain Management:

• NSAIDs should be used to address pain, which should be measured using validated scales (e.g., VAS) 1
• Intralesional corticosteroids can be considered for acute, localized flares even in stage 3 disease 1

Topical Therapy:

• Clindamycin 1% solution twice daily can be applied to affected skin regions as adjunctive therapy 1, 4
• Antiseptic washes may help reduce bacterial colonization 1
• Resorcinol cream represents another topical option for disease management 5, 4

Hormonal Therapy (for appropriate candidates):

• Spironolactone 100-150 mg daily showed improvement in 85% of patients in one series, though none with severe HS achieved complete clearance 1
• Metformin 500 mg 2-3 times daily may be beneficial, particularly in patients with features of polycystic ovarian syndrome or metabolic syndrome 1
• Combined oral contraceptives or other anti-androgens can be considered in female patients 1

Therapies to Avoid in Stage 3 HS

• Do NOT offer isotretinoin unless there are concomitant moderate-to-severe acneiform lesions of the face or trunk 1
• Do NOT offer etanercept, as it has been shown ineffective for moderate-to-severe HS 1
• Do NOT offer cryotherapy during acute phases due to procedural pain 1
• Do NOT offer microwave ablation 1

Critical Pitfalls to Avoid

Antibiotic Resistance Concerns:

• While the infectious disease team deemed antibiotics unnecessary, if bacterial superinfection develops, short-term targeted therapy may still be needed 6
• Long-term antibiotic use should be avoided in stage 3 disease as it rarely provides adequate control and promotes resistance 6

Inadequate Biologic Dosing:

• Standard every-other-week adalimumab dosing (40 mg) may be insufficient for stage 3 disease 1
• Consider weekly dosing or coordination with surgery for optimal outcomes 1

Delayed Surgical Referral:

• Stage 3 disease warrants immediate referral to dermatology and surgical consultation 1
• Medical management alone is unlikely to achieve remission in extensive disease with sinus tracts and scarring 1

Quality of Life Considerations

• Quality of life should be measured using validated instruments (e.g., DLQI) and tracked throughout treatment 1
• Lesion counts and flare frequency should be documented to assess treatment response 1
• Patient education materials should be provided to support self-management strategies 1