What is the management of hidradenitis (inflammation of the apocrine glands)?

From the Guidelines

Management of hidradenitis suppurativa requires a comprehensive approach tailored to disease severity, with the most effective treatment being adalimumab for severe or refractory cases, as evidenced by the highest quality study 1.

Overview of Treatment Approach

The treatment of hidradenitis suppurativa (HS) should be based on the evaluation of the inflammatory components as well as the scarring, and should be directed by evidence-based guidelines 1.

Medical Management

For mild disease, topical clindamycin 1% solution or gel applied twice daily for 12 weeks is recommended, or oral tetracycline 500mg twice daily for 4 months 1.

• For moderate to severe disease, combination therapy with clindamycin 300mg twice daily plus rifampin 600mg once daily for 10 weeks may be considered 1.
• For severe or refractory cases, biologics like adalimumab (initial dose 160mg, then 80mg at week 2, followed by 40mg weekly) are effective by targeting TNF-alpha, with a HiSCR response rate of 59% versus 28% for placebo 1.

Surgical Management

Surgical interventions range from incision and drainage for acute painful abscesses to wide excision of chronically affected tissue for definitive treatment.

Lifestyle Modifications

Lifestyle modifications are crucial, including weight reduction, smoking cessation, wearing loose clothing, and avoiding shaving affected areas.

Pain Management

Pain management should be addressed with appropriate analgesics, and adjuvant therapy such as pain management, weight loss, tobacco cessation, treatment of superinfections, and application of appropriate dressings should be offered as needed 1.

Disease Severity Assessment

The treating physician should be familiar with disease severity scores, especially Hurley staging, physician global assessment, and others, and the routine use of patient-reported outcomes including DLQI, itch, and pain assessment (Visual Analogue Scale) is strongly recommended 1.

From the FDA Drug Label

Hidradenitis Suppurativa (HS) (1.8): treatment of moderate to severe hidradenitis suppurativa in patients 12 years of age and older.

Hidradenitis Suppurativa (2. 6): Adults:◦ Day 1: 160 mg (given in one day or split over two consecutive days)◦ Day 15: 80 mg ◦ Day 29 and subsequent doses: 40 mg every week or 80 mg every other week Adolescents 12 years of age and older: Adolescent WeightRecommended Dosage 30 kg (66 lbs) to less than 60 kg (132 lbs)Day 1: 80 mg Day 8 and subsequent doses: 40 mg every other week 60 kg (132 lbs) and greaterDay 1: 160 mg (given in one day or split over two consecutive days)Day 15: 80 mg Day 29 and subsequent doses: 40 mg every week or 80 mg every other week

The management of hidradenitis suppurativa involves the use of adalimumab (SQ), with the following dosages:

• Adults: 160 mg on Day 1,80 mg on Day 15, and 40 mg every week or 80 mg every other week starting on Day 29.
• Adolescents 12 years of age and older:
  • 30 kg to less than 60 kg: 80 mg on Day 1, and 40 mg every other week starting on Day 8.
  • 60 kg and greater: 160 mg on Day 1,80 mg on Day 15, and 40 mg every week or 80 mg every other week starting on Day 29. 2 2 2

From the Research

Management of Hidradenitis Suppurativa

• The management of hidradenitis suppurativa (HS) can be challenging and often requires a multimodal approach with the use of on- and off-label medications 3.
• A comprehensive and updated algorithm for the management of HS involves the assessment of severity, extent of disease, and impact on patient quality of life, followed by comorbidity screening 3.
• The treatment of HS typically involves a multimodal approach, including:
  • Topical therapies
  • Systemic and topical antibiotics
  • Retinoids
  • Hormonal and metabolic therapies
  • Biologics and small molecule inhibitors
  • Systemic immunosuppressants
  • Surgical treatment
  • Pain management
  • Lifestyle modifications
  • Adjunctive treatment
  • Wound care
  • Flare therapy 3

Treatment Options

• Antibacterial and anti-tumour necrosis factor therapies have been shown to be effective in the treatment of HS 4.
• Tetracycline, doxycycline, and lymecycline have been found to be effective and safe in the treatment of HS, with tetracycline providing the greatest clinical improvement 5.
• Adalimumab 40 mg weekly has been shown to improve quality of life in patients with HS, with moderate-quality evidence supporting its effectiveness 6.
• Infliximab 5 mg kg(-1) has also been found to be effective in improving quality of life in patients with HS, with moderate-quality evidence supporting its effectiveness 6.

Pharmacology of Antibiotic Therapy

• Antibiotics are recognized as first-line treatments for HS, but the data on their efficacy are limited 7.
• The role of bacteria, infections, and superinfections in HS is still debated and controversial, and antibiotics should not be replaced by new biological therapies 7.
• A better understanding of HS pathogenesis has been used to improve treatment strategies, and antibiotic therapy is an effective treatment of patients with HS 7.