What is the long-term treatment for Hidradenitis Suppurativa (HS)?

Long-Term Treatment for Hidradenitis Suppurativa

For long-term management of HS, initiate oral tetracyclines (doxycycline or lymecycline) for at least 12 weeks with planned treatment breaks, escalate to clindamycin-rifampicin combination for 10-12 weeks if inadequate response, and transition to weekly adalimumab 40 mg for moderate-to-severe disease unresponsive to antibiotics, with concurrent surgical intervention for extensive disease with sinus tracts. 1, 2

Initial Long-Term Medical Management

First-Line Systemic Therapy

• Start with oral tetracyclines such as doxycycline 100 mg once or twice daily or lymecycline 408 mg once or twice daily for at least 12 weeks 1, 2
• Consider treatment breaks after completing antibiotic courses to assess ongoing need and limit antimicrobial resistance risk 1, 2
• Tetracyclines can be extended up to 4 months (16 weeks) for more widespread mild disease 2

Second-Line Systemic Therapy

• Escalate to clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks if tetracyclines fail 1, 2
• This combination demonstrates response rates of 71-93%, significantly superior to tetracycline monotherapy 2
• Can be repeated intermittently as needed for disease flares 2

Biologic Therapy for Moderate-to-Severe Disease

Adalimumab (First-Line Biologic)

• Offer adalimumab 40 mg weekly to patients with moderate-to-severe HS unresponsive to conventional systemic therapy 1, 3
• Dosing schedule: 160 mg at week 0 (single dose or split over two consecutive days), 80 mg at week 2, then 40 mg weekly starting at week 4 2, 3
• FDA-approved for patients 12 years of age and older 3
• Assess response at 12-16 weeks using HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) 2

Critical Pitfall: Do not dose adalimumab at 40 mg every other week—this is insufficient and not recommended for HS 4

Alternative Biologics After Adalimumab Failure

• Consider infliximab 5 mg/kg at weeks 0,2,6, then every 8 weeks for patients who fail adalimumab 1, 2
• Secukinumab demonstrates response rates of 64.5-71.4% in adalimumab-failure patients at 16-52 weeks 2
• Ustekinumab is an alternative option targeting different cytokine pathways 2

Alternative Systemic Therapies

Retinoids

• Consider acitretin 0.3-0.5 mg/kg/day in males and non-fertile females unresponsive to antibiotic therapies 1, 2
• Feasible for long-term use but requires strict contraception in females of reproductive age due to teratogenicity 5

Other Immunomodulators

• Consider dapsone starting at 50 mg daily and titrating up to 200 mg daily for patients unresponsive to antibiotics 1, 2
• Metformin can be considered in patients with concomitant diabetes mellitus or females with polycystic ovary syndrome 1

Surgical Management

Indications for Surgery

• Consider extensive excision to minimize recurrence rate in patients with Hurley Stage III disease or extensive sinus tracts and scarring 1, 2
• Surgery is often necessary for lasting cure, especially in advanced disease 2, 6
• Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 2

Surgical Options

• Deroofing for recurrent nodules and tunnels 2
• Radical surgical excision for extensive disease 1, 2, 6
• Healing by secondary intention, skin grafts, or flap reconstruction 2, 6

Essential Long-Term Monitoring and Comorbidity Management

Baseline and Ongoing Screening

• Screen for depression, anxiety, and cardiovascular risk factors (diabetes, hypertension, hyperlipidemia, central obesity) at baseline and regularly 1, 2
• Monitor for inflammatory bowel disease if persistent gastrointestinal symptoms reported 1
• In patients with long-standing moderate-to-severe HS, monitor for fistulating gastrointestinal disease, inflammatory arthritis, genital lymphoedema, cutaneous squamous cell carcinoma, and anemia 1

Treatment Response Monitoring

• Measure treatment response using pain VAS, quality of life instruments (DLQI), and inflammatory lesion count 1, 2
• For patients on adalimumab, use HiSCR at 12-16 weeks to assess response 2, 3
• Reassess at 12 weeks after initiating any new systemic therapy 2

Mandatory Lifestyle Modifications

Risk Factor Management

• Refer to smoking-cessation services where relevant, as tobacco use is associated with worse outcomes (odds ratio 36) 1, 7
• Refer to weight-management services where relevant, as obesity significantly worsens disease (odds ratio 33) 1, 7

Supportive Care

• Provide patient information leaflets to all patients 1
• Treat pain with NSAIDs for symptomatic relief 2
• Provide appropriate dressings for pus-producing lesions 1

Multidisciplinary Approach

• Manage via a multidisciplinary team approach, particularly when considering surgical interventions 1
• For Hurley Stage III (severe) disease, consider immediate referral to dermatology secondary care 1
• Document Hurley stage at baseline for the worst-affected region in all patients 1

Critical Caveat: Non-surgical methods rarely result in lasting cure for advanced disease with extensive sinus tracts and scarring 2, 4. Early aggressive intervention is essential to prevent irreversible skin damage 8.